IWSDS2024

Response Generation for Cognitive Behavioral
Therapy with Large Language Models:Comparative Study with Socratic Questioning
Na r a I ns t i tut e of Sc i en ce a nd Te c hno l ogy ( NAI S T ) , J a p a n
K e n t a I z um i , Hi r ok i Ta na ka , Ka zu hi r o Sh i d a r a, Sa t o s h i Na k amu ra
Os a k a Uni v e r s i ty, J a pa n
Hi ro yo s hi Ada c hi , D ai s uk e Ka n aya ma, Tak as h i K u do1

2024/3/9

TAPAS SUPPORTED BY ANR-CREST

Global Rise in Mental Health Issues and the Digital Response
It is estimated that 970 million people worldwide suffered from mental illness in 2019,in a situation where there is a global shortage of psychiatrists and therapists.
Global prevalence of mental disorder

Source: IHME, Gbd results tool

Global mental health workers in 2020
(median number per 100 000 population)
Psychiatrists

1.7

Mental healthnurses

3.8

Psychologists

0.7

Social workers

0.7

Source: WHO, Mental Health Atlas 2020

Mobile applications are being developed to facilitate access to mental healthcare services.
One of the key players is conversational agents. [Abd-Alrazaq et al., 2021]
2

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Cognitive Behavioral Therapy（CBT） [Beck, 2020]
Situation

AutomaticThoughts

Mood“My friend never responds.”① Identify
The friend must hate me.

Anxiety② Correct
Maybe she/he is busy.

Improved

Key points of CBT: (1) identify and (2) correct automatic thought.
3

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Chatbot for Mental Health Care
Woebot [Fitzpatrick KK et al., 2017]• Provides chat services based on a custom CBT template.
• Begins with general questions and emotion testing, and provides
several options for the user to choose from.

Wysa [Inkster B et al., 2018]• CBT and some other counseling techniques are used.
• Analyzes user input and responds according to predefined rules.
A review up to 2019 reported that most of these systems generate
responses based on pre-defined rules. [Abd-Alrazaq AA et al., 2021]
4TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Examples of LLM-Based Dialogue Systems
Therapy Empowerment Opportunity (TEO)[Danieli et al., 2022]
TEO makes two types of responses.
1) Responses from the pre-defined ABC questions(Activation, Belief, and Consequence).
2) Responses generated by LLM to follow-up users.
Improvement in depressive tendencies was observed in RCT.

Retrieved from [Mousavi et al., 2021, Fig. 2])
5©KENTA IZUMI, ALL RIGHTS RESERVED

2024/3/9

Transition to LLM-based dialogue systems

Rule-based
Dialogue Systems

LLM-based
Dialogue SystemsResponse quality

Safety△〇“Conversations are shallow, confusing, or tooshort.“ [Abd-Alrazaq AA et al., 2021]

Developers can control and supervise
the responses in advance.

〇△

LLMｓ outperform humans in some tasks.
Better for mental healthcare services?
Does it improve the effectiveness of CBT?

Developers cannot control and supervise
the responses in advance.

Investigate how the quality of dialogue and the effectiveness of CBT can be changed
by using responses generated by LLMs, compared to the predefined ones.
6TAPAS SUPPORTED BY ANR-CREST

2024/3/9Dialogue Scenario: ABC questions
Ask about situations, mood, thoughts raised in the mind at that time.

7OrderIntention

Utterance

1Situation

Let’s address your concerns together. Are you currently facing any issues ordifficulties? If you feel comfortable doing so, please share what’s troubling you

2

Mood

How did you feel at that time?

3

Initial Mood Intensity

On a scale of 0 to 100, where 0 is no problem at all and 100 isa huge problem, how intense is that feeling?

4

Automatic Thought

What thoughts came to your mind at that time?

5

Automatic Thought

I see. Are there any others? Please share anything that comes to mind.

6

Automatic Thought

Please tell me the strongest thought among those that came to your mind

7

Automatic Thought

The thoughts that come to mind in response to a situation are called automatic
thoughts. Today we are going to delve into your thoughts. Is that okay?
©KENTA IZUMI, ALL RIGHTS RESERVED

2024/3/9

Dialogue Scenario: Socratic Question (SQ)
Socratic questioning is a questioning technique that helps clients explore their ideas andbeliefs, think critically about them, expand their horizons, and arrive at a more realistic
and adaptive perspective. [Vittorio et al., 2022][Overholser, 2010][Kazantzis et al., 2014]
Order

8Utterance

8

If the automatic thought is correct, what is the basis for it?

9

On the other hand, if your automatic thought is incorrect, what evidence can you think of?

10

Can you think of any other perspectives regarding the situation that’s troubling you,aside from your current automatic thoughts?

11

What would be the worst possible outcome in this situation?

12

What would be the best possible outcome in this situation?

13

What do you think is the most realistic outcome in this situation?
©KENTA IZUMI, ALL RIGHTS RESERVED

2024/3/9

Dialogue Scenario: Closing Remarks
At the end, the intensity of mood was asked again and ended with a greeting.
Mood intensity heard in Utterance 3, 14 will be used for evaluation.

9OrderIntention

14

Mood Intensity
at the end

15

Closing Remark

Utterance
Now, how intense is the feeling you initially had?

Please rate it again on a scale from 0 to 100.

If your mood has changed, that’s a sign that you’ve successfully organized yourthoughts. That’s it for today. Good job!

©KENTA IZUMI, ALL RIGHTS RESERVED

2024/3/9

Effectiveness verification through LLM response generation
Comparison of 3 types of Dialogue Scenarios
Utt. 1-7
Utt. 8-13
Utt. 14, 15

ABC questions
SQ

LLM

LLM + SQ

Closing Remarks

Focus
How can each dialogue system help people rethink their automatic thoughts, arrive at morebalanced thoughts, and thus improve their mood after asking ABC questions?
10©KENTA IZUMI, ALL RIGHTS RESERVED2024/3/9

Effectiveness verification through LLM response generation
Two types of LLMs with different characteristics• OsakaED: Small (1.6B) but dedicated to empathetic counseling dialogue on social media.
• GPT-4 : General purpose model with state-of-the-art capabilities.

Comparison of 5 systems
1. SQ
2. OsakaED3. OsakaED+SQ
4. GPT-4
5. GPT-4+SQ

11

SQ is uttered as per the scenario.
Response generated by OsakaED is uttered.
Response generated by OsakaED and SQ are uttered.
Response generated by GPT-4 is uttered.
Response generated by GPT-4 and SQ are uttered.

©KENTA IZUMI, ALL RIGHTS RESERVED

2024/3/9

OsakaED
Osaka Social Media Counseling Dataset# Dialogues# Utterances# Pairs of Contexts and Counselor Utterances

2077
62066
29062

Training

Training Data: 90% Verification Data: 10%
Base Model
NTT Japanese Transformer Encoder Decoder dialogue model finetune with
EmpatheticDialogues dataset
Training perplexity was found to be decreasing and the model with the lowest Validation
perplexity was used.

12TAPAS SUPPORTED BY ANR-CREST

2024/3/9

GPT-4
System Message
We employed the Japanese-translated version of CBT prompt designed by[Kumar et al., 2022], which was validated by GPT-3.
The following is a conversation with a coach. The coach helps the Human understand how their thoughts, feelings, andbehaviors influence each other. If the Human demonstrates negative thoughts, the coach helps the Human replace themwith more realistic beliefs. The coach has strong interpersonal skills.

When combining Socrates questions, GPT-4 is urged not to ask questions.
The following is a conversation with the coach. The coach does not ask questions. The coach is …

Dialogue Context
All dialogue history is entered after the System Message.
13TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Experiment Procedure
105 workers were recruited through the crowdsourcing platform CrowdWorks.
Subjects were asked to complete
K6(Depression Scale), Gender, Age, Crowd Sourcing ID
Chat with one of the 5 systems using LINE

SQ

OsakaED

OsakaED+SQ

GPT-4

GPT-4+SQ

Subjects were asked to complete
Cognitive Change Immediate Scale(CC-immediate), Questionnaire, Free text description# valid answers
14241413
TAPAS SUPPORTED BY ANR-CREST

17172024/3/9

Total 85

Evaluation Scale: Mood Change and CC-immediate
Mood Change
In Utter. 3 and 14, subjects were asked about the intensity of their mood (on a scale of 0-100).
Mood Change was calculated using the following formula.
𝑀𝑜𝑜𝑑 𝐶ℎ𝑎𝑛𝑔𝑒 = −𝑀𝑜𝑜𝑑 𝐼𝑛𝑡𝑒𝑛𝑠𝑖𝑡𝑦 𝑎𝑡 𝑡ℎ𝑒 𝑒𝑛𝑑 − (𝐼𝑛𝑖𝑡𝑖𝑎𝑙 𝑀𝑜𝑜𝑑 𝐼𝑛𝑡𝑒𝑛𝑠𝑖𝑡𝑦)
𝐼𝑛𝑖𝑡𝑖𝑎𝑙 𝑀𝑜𝑜𝑑 𝐼𝑛𝑡𝑒𝑛𝑠𝑖𝑡𝑦

Cognitive Change Immediate Scale (CC-immediate) [Schmidt et al., 2019]
5 questions on a 7-point Likert scale to measure cognitive change with single-session CBT.
A stronger relationship between cognitive change and symptom improvement wasobserved in the earlier stages of treatment.
15

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Evaluation Scale: Questionaire with 15 items

*

評価項目

質問内容

Naturalness

Q1. The system's speech was human and natural.

Ease

Q2. We could easily continue the dialogue.

Enjoyment

Q3. I enjoyed interacting with the system.

User’s empathy

Q4. I could relate to the system's speech.

AttentivenessQ5. The system was interested in you and willing to talk to you.

Trust

Q6. I felt I could trust what the system told me.

Personality

Q7. I could feel the individuality and personality of the system.

AgencyQ8. I felt the system was speaking with its own ideas.

Topic

Q9. I felt the system had a topic we wanted to talk about.

Emotion

Q10. The system felt emotional.

Consistency

Q11. The system's utterances were consistent and not contradictory.

Engagement

Q12. I could get lost in this dialogue.

RespeakQ13. I want to talk to this system again.

System’s empathy

Q14. The system showed empathy.

initiative

Q15. I was able to lead the dialogue.

* The same questions as [Sugiyama, et al. 2021], and following them, an 11-point Likert scale was used for all questions.
16

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Result
GPT-4 was rated highest in mood change, CC-immediate, and almost all questionnaire items.

17

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Comparison of responses generated by SQ and LLM
SQ vs. OsakaED

Significant increases in “initiative” and adecrease in “consistency” were found.

18

SQ vs. GPT-4

Many items showed significant improvement,including mood change, “empathy”, and “emotion”.

©KENTA IZUMI, ALL RIGHTS RESERVED

2024/3/9

Effect of adding LLM-generated responses to SQSQ vs. OsakaED+SQ

There was a decrease in “consistency”

19

SQ vs. GPT-4+SQ

many items showed significant improvement,
including mood change, “empathy”, and “emotion.”©KENTA IZUMI, ALL RIGHTS RESERVED

2024/3/9

Effect of adding SQ to LLM-generated responses
OsakaED vs. OsakaED+SQ, GPT-4 vs GPT-4+SQ• No significantly different for all items.
• However, there are increase for many items in OsakaED+SQ and decrease for GPT-4+SQ.
• In the GPT-4 and GPT-4+SQ, Socratic question-like utterances were found in all dialogues.

20©KENTA IZUMI, ALL RIGHTS RESERVED

2024/3/9

SummaryPriciple Findings
 GPT-4 shows high counseling ability and significantly improved SQ.
 GPT-4 was found to be able to understand and use Socratic questions.
 In contrast, we saw LLMs trained with real counseling datasets do not necessarily
improve predefined SQ.

Limitations
 This is a small-scale experiment with a limited number of crowdsourced subjects.
 The response delay of the systems was not regulated.
 A long-term experiment with a larger sample size is needed to assess the effectivenessof CBT accurately.
21

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Ethical Use of LLMs in real life mental health care services
Safety Issues of LLMs
• Developers cannot know in advance what response will be generated and ensure
the safety of the response.
• The "hallucination" phenomenon could lead to fabricated medical information.

Presenting LLM-generated responses in real-life services may raise ethical issues
Possible Safe Usecase (Human in the loop)• Produce example responses or templates with human experts in advance.
• Understand the user input and select predefined responses.
• Monitor and estimate the user’s mental state. etc.
22

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

References
Shidara K, Tanaka H, Adachi H, Kanayama D, Sakagami Y, Kudo T, and Nakamura S (2022) An Analysis of Questions to Evaluate an AutomaticThoughtin Cognitive Behavior Therapy with a Virtual Agent. The 36th Annual Conference of the Japanese Society for Artificial Intelligence, p.
2I6OS9b02
Inkster B, Sarda S, Subramanian V (2018) An Empathy-Driven, Conversational Artificial Intelligence Agent (Wysa) for Digital Mental Well-Being:
Real-World Data Evaluation Mixed-Methods Study, JMIR Mhealth Uhealth 2018;6(11):e12106
Institute for Health Metrics and Evaluation, “Gbd results tool.”, http://ghdx.healthdata.org/gbd-results-tool?params=gbd-api2019permalink/cb9c37d9454c80df77adaed394d7fc0f, accessed 14 October 2023.
Fitzpatrick KK, Darcy A, Vierhile M. (2017) Delivering Cognitive Behavior Therapy to Young Adults With Symptoms of Depression and Anxiety
Using a Fully Automated Conversational Agent (Woebot): A Randomized Controlled Trial. JMIR Ment Health. 2017 Jun 6;4(2):e19. doi:
10.2196/mental.7785. PMID: 28588005; PMCID: PMC5478797.
Abd-Alrazaq AA, Alajlani M, Ali N, Denecke K, Bewick BM, Househ M (2021) Perceptions and Opinions of Patients About Mental Health Chatbots:
Scoping Review, J Med Internet Res 2021;23(1):e17828
Sugiyama H, Mizukami M, Arimoto T, Narimatsu H, Chiba Y, Nakajima H, Meguro T (2021) Empirical Analysis of Training Strategies of Transformerbased Japanese Chit-chat Systems, arXiv, cs.CL, preprint arXiv:2109.05217
World Health Organization. World mental health report: transforming mental health for all, 2022.
https://www.who.int/publications/i/item/9789240049338, Licence: CC BY-NC-SA 3.0 IGO
Harsh Kumar, Ilya Musabirov, Jiakai Shi, Adele Lauzon, Kwan Kiu Choy, Ofek Gross, Dana Kulzhabayeva, and Joseph Jay Williams. Exploring thedesign of prompts for applying gpt-3 based chatbots: A mental wellbeing case study on mechanical turk. arXiv preprint arXiv:2209.11344, 2022.

23

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Dialogue Scenario: ABC questions
Ask about situations, mood, thoughts raised in the mind at that time.
発話順

24

発話の意図

発話

1

Situation

Let’s address your concerns together. Are you currently facing any issues ordifficulties? If you feel comfortable doing so, please share what’s troubling you.

2

Mood

How did you feel at that time?

3

Initial Mood Intensity

On a scale of 0 to 100, where 0 is no problem at all and 100 isa huge problem, how intense is that feeling?

4

Automatic Thought

What thoughts came to your mind at that time?

5

Automatic Thought

I see. Are there any others? Please share anything that comes to mind.

6

Automatic Thought

Please tell me the strongest thought among those that came to your mind

7

Automatic Thought

The thoughts that come to mind in response to a situation are called automatic
thoughts. Today we are going to delve into your thoughts. Is that okay?
©KENTA IZUMI, ALL RIGHTS RESERVED

2024/3/9

Dialogue Example (ABC Questions)Let’s address your concerns together. Are you currently facing any issues ordifficulties? If you feel comfortable doing so, please share what’s troubling you.
I have skin problems and acne that won't go away for a long time.
How did you feel at that time?
It is painful. I hope it will go away soon.
On a scale of 0 to 100, where 0 is no problem at all and 100 isa huge problem, how intense is that feeling?
80
What thoughts came to your mind at that time?
25

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Dialogue Example (ABC Questions)
I hope it gets better soon. Why can't I get well?
I see. Are there any others? Please share anything that comes to mind.
Is that kind of constitution?
Please tell me the strongest thought among those that came to your mind
I want to get well soon.
The thoughts that come to mind in response to a situation are called automaticthoughts. Today we are going to delve into your thoughts. Is that okay?
Yes.

26

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Dialogue Example（GPT-４）
Thank you. Let’s dig deeper into the thoughts that arise
from that “I want to heal fast” feeling. How do you feel thatthought is affecting you? How does it affect your behavior and daily life?

I check when looking in the mirror and pay attention to the skin and diet.
Your automatic thoughts strongly express your desire to “heal quickly”. This thought
prompts you to take action and make it easier for you to try to live a healthier life.
You once thought, “Why can’t I get well?” but in fact, that thought may not be inalignment with reality. I would like to propose a new way of looking at it. You canhelp yourself more by looking at it from a realistic perspective, as in, “I have control
over my skin condition,” and “I can improve it over time if I take proper care of myskin problems.” What do you think about this new view?

27

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Dialogue Example（OsakaED）
It’s hard to have skin problems and acne that won’t go away for a long time...
Yes, it is. It’s hard.
Why is it that skin problems and acne don’t go away all the time...

28

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Transition to a generation-based dialogue system
Rule-based Chatbot

Poor understanding of user input
Context-independent responses“Conversations are shallow,confusing,or too short.“[Abd-Alrazaq AA et al., 2021]

Chat with an LLM

Better understanding of user input
Higher quality response

Improve the quality of dialogue?
Does it improve the effectivenessof CBT?

Investigate how the quality of dialogue and the effectiveness of CBT can bealtered by using responses generated from large-scale language models (LLMs).
29

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Experiment
Recruit105 workers were recruited through the crowdsourcing platform CrowdWorks.

Before the dialogue begins
Subjects will be asked to complete the following items.

K6 (Depression Scale), Gender, Age, Crowd Sourcing ID

Dialogue• Chat using the Social Media: LINE.
• In Q3 and 14, subjects were asked about the intensity of their mood (on a scale of 0-100). Mood
Change was calculated using the following formula.
𝑀𝑜𝑜𝑑 𝐶ℎ𝑎𝑛𝑔𝑒 = −30

𝑀𝑜𝑜𝑑 𝐼𝑛𝑡𝑒𝑛𝑠𝑖𝑡𝑦 𝑎𝑡 𝑡ℎ𝑒 𝑒𝑛𝑑 − (𝐼𝑛𝑖𝑡𝑖𝑎𝑙 𝑀𝑜𝑜𝑑 𝐼𝑛𝑡𝑒𝑛𝑠𝑖𝑡𝑦)
𝐼𝑛𝑖𝑡𝑖𝑎𝑙 𝑀𝑜𝑜𝑑 𝐼𝑛𝑡𝑒𝑛𝑠𝑖𝑡𝑦

TAPAS SUPPORTED BY ANR-CREST

2024/3/9

Experiment
After the end of the dialogue
Subjects will be asked to complete the following items.

• Cognitive Change Immediate Scale (5 questions on a 7-point Likert scale)• 15 questions to assess the quality of dialogue• Free text descriptions for improving the dialogue system# valid samples
85 valid samples were collected.
1. SQ:
2. OsakaED:3. OsakaED+SQ:
4. GPT-4:
5. GPT-4+SQ:
31

24
14
13
17
17
TAPAS SUPPORTED BY ANR-CREST

2024/3/9