# Risks from Language Models for Automated Mental Healthcare: Ethics and Structure for Implementation

arXiv: https://arxiv.org/abs/2406.11852 · HTML: https://mlsanity.com/paper/2406.11852/

## Key facts

- Cited by 27 papers in the map (data through 14 Oct 2026).
- Builds on 48 of its 107 references that are in the map.
- First posted on arXiv 2 Apr 2024.

## Builds on (most cited first, 30 of 48)

- [GPT-4 Technical Report](https://mlsanity.com/paper/2303.08774/) (2023)
- [Training language models to follow instructions with human feedback](https://mlsanity.com/paper/2203.02155/) (2022)
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- [Training Verifiers to Solve Math Word Problems](https://mlsanity.com/paper/2110.14168/) (2021)
- [Direct Preference Optimization: Your Language Model is Secretly a Reward Model](https://mlsanity.com/paper/2305.18290/) (2023)
- [On the Opportunities and Risks of Foundation Models](https://mlsanity.com/paper/2108.07258/) (2021)
- [Training a Helpful and Harmless Assistant with Reinforcement Learning from Human Feedback](https://mlsanity.com/paper/2204.05862/) (2022)
- [Generative Agents: Interactive Simulacra of Human Behavior](https://mlsanity.com/paper/2304.03442/) (2023)
- [Mistral 7B](https://mlsanity.com/paper/2310.06825/) (2023)
- [Universal and Transferable Adversarial Attacks on Aligned Language Models](https://mlsanity.com/paper/2307.15043/) (2023)
- [Constitutional AI: Harmlessness from AI Feedback](https://mlsanity.com/paper/2212.08073/) (2022)
- [GPQA: A Graduate-Level Google-Proof Q&A Benchmark](https://mlsanity.com/paper/2311.12022/) (2023)
- [Voyager: An Open-Ended Embodied Agent with Large Language Models](https://mlsanity.com/paper/2305.16291/) (2023)
- [Fine-Tuning Language Models from Human Preferences](https://mlsanity.com/paper/1909.08593/) (2019)
- [CommonsenseQA: A Question Answering Challenge Targeting Commonsense Knowledge](https://mlsanity.com/paper/1811.00937/) (2018)
- [AgentBench: Evaluating LLMs as Agents](https://mlsanity.com/paper/2308.03688/) (2023)
- [Red Teaming Language Models with Language Models](https://mlsanity.com/paper/2202.03286/) (2022)
- [Discovering Language Model Behaviors with Model-Written Evaluations](https://mlsanity.com/paper/2212.09251/) (2022)
- [Red Teaming Language Models to Reduce Harms: Methods, Scaling Behaviors, and Lessons Learned](https://mlsanity.com/paper/2209.07858/) (2022)
- [Long Range Arena: A Benchmark for Efficient Transformers](https://mlsanity.com/paper/2011.04006/) (2020)
- [DecodingTrust: A Comprehensive Assessment of Trustworthiness in GPT Models](https://mlsanity.com/paper/2306.11698/) (2023)
- [XSTest: A Test Suite for Identifying Exaggerated Safety Behaviours in Large Language Models](https://mlsanity.com/paper/2308.01263/) (2023)
- [Safety-Tuned LLaMAs: Lessons From Improving the Safety of Large Language Models that Follow Instructions](https://mlsanity.com/paper/2309.07875/) (2023)
- [Are aligned neural networks adversarially aligned?](https://mlsanity.com/paper/2306.15447/) (2023)
- [Ghost in the Minecraft: Generally Capable Agents for Open-World Environments via Large Language Models with Text-based Knowledge and Memory](https://mlsanity.com/paper/2305.17144/) (2023)
- [MEDITRON-70B: Scaling Medical Pretraining for Large Language Models](https://mlsanity.com/paper/2311.16079/) (2023)
- [MM-SafetyBench: A Benchmark for Safety Evaluation of Multimodal Large Language Models](https://mlsanity.com/paper/2311.17600/) (2023)
- [QuALITY: Question Answering with Long Input Texts, Yes!](https://mlsanity.com/paper/2112.08608/) (2021)
- [SafetyBench: Evaluating the Safety of Large Language Models](https://mlsanity.com/paper/2309.07045/) (2023)
- [The 'Problem' of Human Label Variation: On Ground Truth in Data, Modeling and Evaluation](https://mlsanity.com/paper/2211.02570/) (2022)

## Built on by (most cited first, 27 of 27)

- [Emergent Misalignment: Narrow finetuning can produce broadly misaligned LLMs](https://mlsanity.com/paper/2502.17424/) (2025)
- [BetterBench: Assessing AI Benchmarks, Uncovering Issues, and Establishing Best Practices](https://mlsanity.com/paper/2411.12990/) (2024)
- [Expressing stigma and inappropriate responses prevents LLMs from safely replacing mental health providers](https://mlsanity.com/paper/2504.18412/) (2025)
- [CounselBench: A Large-Scale Expert Evaluation and Adversarial Benchmarking of Large Language Models in Mental Health Question Answering](https://mlsanity.com/paper/2506.08584/) (2025)
- [Aloe: A Family of Fine-tuned Open Healthcare LLMs](https://mlsanity.com/paper/2405.01886/) (2024)
- [More than Marketing? On the Information Value of AI Benchmarks for Practitioners](https://mlsanity.com/paper/2412.05520/) (2024)
- [Acceptable Use Policies for Foundation Models](https://mlsanity.com/paper/2409.09041/) (2024)
- [CBT-Bench: Evaluating Large Language Models on Assisting Cognitive Behavior Therapy](https://mlsanity.com/paper/2410.13218/) (2024)
- [Measuring Free-Form Decision-Making Inconsistency of Language Models in Military Crisis Simulations](https://mlsanity.com/paper/2410.13204/) (2024)
- [CRADLE Bench: A Clinician-Annotated Benchmark for Multi-Faceted Mental Health Crisis and Safety Risk Detection](https://mlsanity.com/paper/2510.23845/) (2025)
- [Just a Scratch: Enhancing LLM Capabilities for Self-harm Detection through Intent Differentiation and Emoji Interpretation](https://mlsanity.com/paper/2506.05073/) (2025)
- [Markovian Transformers for Informative Language Modeling](https://mlsanity.com/paper/2404.18988/) (2024)
- [Do No Harm: Exposing Hidden Vulnerabilities of LLMs via Persona-based Client Simulation Attack in Psychological Counseling](https://mlsanity.com/paper/2604.04842/) (2026)
- [DICE: A Framework for Dimensional and Contextual Evaluation of Language Models](https://mlsanity.com/paper/2504.10359/) (2025)
- [One Bias After Another: Mechanistic Reward Shaping and Persistent Biases in Language Reward Models](https://mlsanity.com/paper/2603.03291/) (2026)
- [Using LLM-as-a-Judge/Jury to Advance Scalable, Clinically-Validated Safety Evaluations of Model Responses to Users Demonstrating Psychosis](https://mlsanity.com/paper/2604.02359/) (2026)
- [SAIF: A Comprehensive Framework for Evaluating the Risks of Generative AI in the Public Sector](https://mlsanity.com/paper/2501.08814/) (2025)
- [Seeking Late Night Life Lines: Experiences of Conversational AI Use in Mental Health Crisis](https://mlsanity.com/paper/2512.23859/) (2025)
- [Expert Evaluation and the Limits of Human Feedback in Mental Health AI Safety Testing](https://mlsanity.com/paper/2601.18061/) (2026)
- [Understanding Risk and Dependency in AI Chatbot Use from User Discourse](https://mlsanity.com/paper/2602.09339/) (2026)
- [Receptiveness, Not Sycophancy: Distinguishing Engagement from Deference in Language Models](https://mlsanity.com/paper/2609.26579/) (2026)
- [SEED-SET: Scalable Evolving Experimental Design for System-level Ethical Testing](https://mlsanity.com/paper/2603.01630/) (2026)
- [When LLM Therapists Become Salespeople: Evaluating Large Language Models for Ethical Motivational Interviewing](https://mlsanity.com/paper/2503.23566/) (2025)
- [Two-Stage Voting for Robust and Efficient Suicide Risk Detection on Social Media](https://mlsanity.com/paper/2510.08365/) (2025)
- [Multi-Objective Alignment of Language Models for Personalized Psychotherapy](https://mlsanity.com/paper/2602.16053/) (2026)
- [Psychological Influences of Conversational AI: Research and Design Directions for Reducing Harm and Promoting Well-Being](https://mlsanity.com/paper/2607.25057/) (2026)
- [Right Words, Wrong Moment: A Clinician-Grounded Analysis of Distress in 19,930 Conversations between Young People and ChatGPT](https://mlsanity.com/paper/2609.35953/) (2026)

## Abstract (arXiv)

Amidst the growing interest in developing task-autonomous AI for automated mental health care, this paper addresses the ethical and practical challenges associated with the issue and proposes a structured framework that delineates levels of autonomy, outlines ethical requirements, and defines beneficial default behaviors for AI agents in the context of mental health support. We also evaluate fourteen state-of-the-art language models (ten off-the-shelf, four fine-tuned) using 16 mental health-related questionnaires designed to reflect various mental health conditions, such as psychosis, mania, depression, suicidal thoughts, and homicidal tendencies. The questionnaire design and response evaluations were conducted by mental health clinicians (M.D.s). We find that existing language models are insufficient to match the standard provided by human professionals who can navigate nuances and appreciate context. This is due to a range of issues, including overly cautious or sycophantic responses and the absence of necessary safeguards. Alarmingly, we find that most of the tested models could cause harm if accessed in mental health emergencies, failing to protect users and potentially exacerbating existing symptoms. We explore solutions to enhance the safety of current models. Before the release of increasingly task-autonomous AI systems in mental health, it is crucial to ensure that these models can reliably detect and manage symptoms of common psychiatric disorders to prevent harm to users. This involves aligning with the ethical framework and default behaviors outlined in our study. We contend that model developers are responsible for refining their systems per these guidelines to safeguard against the risks posed by current AI technologies to user mental health and safety. Trigger warning: Contains and discusses examples of sensitive mental health topics, including suicide and self-harm.