Ningjing Tang

Ningjing Tang, Alice Qian, Qiaosi Wang et al.

Content Warning: This paper contains participant quotes and discussions related to mental health challenges, emotional distress, and suicidal ideation. Large language models (LLMs) are increasingly used for mental health support, yet the model safeguards -- particularly refusals to engage with sensitive content -- remain poorly understood from the perspectives of users and mental health professionals (MHPs) and have been reported to cause real-world harms. This paper presents findings from a sequential mixed-methods study examining how LLM refusals are experienced and interpreted in mental health support interactions. Through surveys (N=53) and in-depth interviews (N=16) with individuals using LLMs for mental health support and MHPs, we reveal that refusals are not isolated, single-turn system behaviors but rather constitute dynamic, multi-phase experiences: pre-refusal expectation formation, refusal triggering and encounter, refusal message framing, resource referral provision, and post-refusal outcomes. We contribute a multi-phase framework for evaluating refusals beyond binary policy compliance accuracy and design recommendations for future refusal mechanisms. These findings suggest that understanding LLM refusals requires moving beyond single-turn interactions toward recognizing them as holistic experiences embedded within users' support-seeking trajectories and the broader LLM design pipeline.

Cindy Peng, Megan Chai, Gao Mo et al.

Peer-run organizations (PROs) provide critical, recovery-based behavioral health support rooted in lived experience. As large language models (LLMs) enter this domain, their scale, conversationality, and opacity introduce new challenges for situatedness, trust, and autonomy. Partnering with Collaborative Support Programs of New Jersey (CSPNJ), a statewide PRO in the Northeastern United States, we used comicboarding, a co-design method, to conduct workshops with 16 peer specialists and 10 service users exploring perceptions of integrating an LLM-based recommendation system into peer support. Findings show that depending on how LLMs are introduced, constrained, and co-used, they can reconfigure in-room dynamics by sustaining, undermining, or amplifying the relational authority that grounds peer support. We identify opportunities, risks, and mitigation strategies across three tensions: bridging scale and locality, protecting trust and relational dynamics, and preserving peer autonomy amid efficiency gains. We contribute design implications that center lived-experience-in-the-loop, reframe trust as co-constructed, and position LLMs not as clinical tools but as relational collaborators in high-stakes, community-led care.