Timothy Bickmore

Ian Steenstra, Paola Pedrelli, Weiyan Shi et al.

Large Language Models (LLMs) are increasingly utilized for mental health support; however, current safety benchmarks often fail to detect the complex, longitudinal risks inherent in therapeutic dialogue. We introduce an evaluation framework that pairs AI psychotherapists with simulated patient agents equipped with dynamic cognitive-affective models and assesses therapy session simulations against a comprehensive quality of care and risk ontology. We apply this framework to a high-impact test case, Alcohol Use Disorder, evaluating six AI agents (including ChatGPT, Gemini, and Character.AI) against a clinically-validated cohort of 15 patient personas representing diverse clinical phenotypes. Our large-scale simulation (N=369 sessions) reveals critical safety gaps in the use of AI for mental health support. We identify specific iatrogenic risks, including the validation of patient delusions ("AI Psychosis") and failure to de-escalate suicide risk. Finally, we validate an interactive data visualization dashboard with diverse stakeholders, including AI engineers and red teamers, mental health professionals, and policy experts (N=9), demonstrating that this framework effectively enables stakeholders to audit the "black box" of AI psychotherapy. These findings underscore the critical safety risks of AI-provided mental health support and the necessity of simulation-based clinical red teaming before deployment.

Ian Steenstra, Farnaz Nouraei, Mehdi Arjmand et al.

We introduce a novel application of large language models (LLMs) in developing a virtual counselor capable of conducting motivational interviewing (MI) for alcohol use counseling. Access to effective counseling remains limited, particularly for substance abuse, and virtual agents offer a promising solution by leveraging LLM capabilities to simulate nuanced communication techniques inherent in MI. Our approach combines prompt engineering and integration into a user-friendly virtual platform to facilitate realistic, empathetic interactions. We evaluate the effectiveness of our virtual agent through a series of studies focusing on replicating MI techniques and human counselor dialog. Initial findings suggest that our LLM-powered virtual agent matches human counselors' empathetic and adaptive conversational skills, presenting a significant step forward in virtual health counseling and providing insights into the design and implementation of LLM-based therapeutic interactions.

Mehdi Arjmand, Farnaz Nouraei, Ian Steenstra et al.

We introduce the concept of "empathic grounding" in conversational agents as an extension of Clark's conceptualization of grounding in conversation in which the grounding criterion includes listener empathy for the speaker's affective state. Empathic grounding is generally required whenever the speaker's emotions are foregrounded and can make the grounding process more efficient and reliable by communicating both propositional and affective understanding. Both speaker expressions of affect and listener empathic grounding can be multimodal, including facial expressions and other nonverbal displays. Thus, models of empathic grounding for embodied agents should be multimodal to facilitate natural and efficient communication. We describe a multimodal model that takes as input user speech and facial expression to generate multimodal grounding moves for a listening agent using a large language model. We also describe a testbed to evaluate approaches to empathic grounding, in which a humanoid robot interviews a user about a past episode of pain and then has the user rate their perception of the robot's empathy. We compare our proposed model to one that only generates non-affective grounding cues in a between-subjects experiment. Findings demonstrate that empathic grounding increases user perceptions of empathy, understanding, emotional intelligence, and trust. Our work highlights the role of emotion awareness and multimodality in generating appropriate grounding moves for conversational agents.

Hye Sun Yun, Mehdi Arjmand, Phillip Sherlock et al.

Standardized, validated questionnaires are vital tools in research and healthcare, offering dependable self-report data. Prior work has revealed that virtual agent-administered questionnaires are almost equivalent to self-administered ones in an electronic form. Despite being an engaging method, repeated use of virtual agent-administered questionnaires in longitudinal or pre-post studies can induce respondent fatigue, impacting data quality via response biases and decreased response rates. We propose using large language models (LLMs) to generate diverse questionnaire versions while retaining good psychometric properties. In a longitudinal study, participants interacted with our agent system and responded daily for two weeks to one of the following questionnaires: a standardized depression questionnaire, question variants generated by LLMs, or question variants accompanied by LLM-generated small talk. The responses were compared to a validated depression questionnaire. Psychometric testing revealed consistent covariation between the external criterion and focal measure administered across the three conditions, demonstrating the reliability and validity of the LLM-generated variants. Participants found that the variants were significantly less repetitive than repeated administrations of the same standardized questionnaire. Our findings highlight the potential of LLM-generated variants to invigorate agent-administered questionnaires and foster engagement and interest, without compromising their validity.

Ian Steenstra, Farnaz Nouraei, Timothy W. Bickmore

Learning therapeutic counseling involves significant role-play experience with mock patients, with current manual training methods providing only intermittent granular feedback. We seek to accelerate and optimize counselor training by providing frequent, detailed feedback to trainees as they interact with a simulated patient. Our first application domain involves training motivational interviewing skills for counselors. Motivational interviewing is a collaborative counseling style in which patients are guided to talk about changing their behavior, with empathetic counseling an essential ingredient. We developed and evaluated an LLM-powered training system that features a simulated patient and visualizations of turn-by-turn performance feedback tailored to the needs of counselors learning motivational interviewing. We conducted an evaluation study with professional and student counselors, demonstrating high usability and satisfaction with the system. We present design implications for the development of automated systems that train users in counseling skills and their generalizability to other types of social skills training.

Farnaz Nouraei, Keith Rebello, Mina Fallah et al.

Many laypeople are motivated to improve the health behavior of their family or friends but do not know where to start, especially if the health behavior is potentially stigmatizing or controversial. We present an approach that uses virtual agents to coach community-based volunteers in health counseling techniques, such as motivational interviewing, and allows them to practice these skills in role-playing scenarios. We use this approach in a virtual agent-based system to increase COVID-19 vaccination by empowering users to influence their social network. In a between-subjects comparative design study, we test the effects of agent system interactivity and role-playing functionality on counseling outcomes, with participants evaluated by standardized patients and objective judges. We find that all versions are effective at producing peer counselors who score adequately on a standardized measure of counseling competence, and that participants were significantly more satisfied with interactive virtual agents compared to passive viewing of the training material. We discuss design implications for interpersonal skills training systems based on our findings.

Menglin Zhao, Zhuorui Yong, Ruijia Guan et al.

Serious illness conversations (SICs), discussions between clinical care teams and patients with serious, life-limiting illnesses about their values, goals, and care preferences, are critical for patient-centered care. Without these conversations, patients often receive aggressive interventions that may not align with their goals. Clinical care teams face significant barriers when conducting serious illness conversations with older adult patients in Emergency Department (ED) settings, where most older adult patients lack documented treatment goals. To understand current practices and identify AI support opportunities, we conducted interviews with two domain experts and nine ED clinical care team members. Through thematic analysis, we characterized a four-phase serious illness conversation workflow (identification, preparation, conduction, documentation) and identified key needs and challenges at each stage. Clinical care teams struggle with fragmented EHR data access, time constraints, emotional preparation demands, and documentation burdens. While participants expressed interest in AI tools for information synthesis, conversational support, and automated documentation, they emphasized preserving human connection and clinical autonomy. We present design guidelines for AI tools supporting SIC workflows that fit within existing clinical practices. This work contributes empirical understanding of ED-based serious illness conversations and provides design considerations for AI in high-stakes clinical environments.

Farnaz Nouraei, Zhuorui Yong, Timothy Bickmore

We introduce HealthDial, a dialogue authoring tool that helps healthcare providers and educators create virtual agents that deliver health education and counseling to patients over multiple conversations. HealthDial leverages large language models (LLMs) to automatically create an initial session-based plan and conversations for each session using text-based patient health education materials as input. Authored dialogue is output in the form of finite state machines for virtual agent delivery so that all content can be validated and no unsafe advice is provided resulting from LLM hallucinations. LLM-drafted dialogue structure and language can be edited by the author in a no-code user interface to ensure validity and optimize clarity and impact. We conducted a feasibility and usability study with counselors and students to test our approach with an authoring task for cancer screening education. Participants used HealthDial and then tested their resulting dialogue by interacting with a 3D-animated virtual agent delivering the dialogue. Through participants' evaluations of the task experience and final dialogues, we show that HealthDial provides a promising first step for counselors to ensure full coverage of their health education materials, while creating understandable and actionable virtual agent dialogue with patients.

Ian Steenstra, Timothy W. Bickmore

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. We discuss four use cases in detail: monitoring real user interactions, evaluation with simulated patients, benchmarking and comparative analysis, and identifying unexpected outcomes. The proposed ontology offers a foundational step towards establishing safer and more responsible innovation in the domain of AI-driven mental health support.