Towards Richer AI-Assisted Psychotherapy Note-Making and Performance Benchmarking

Psychotherapy note-making is crucial for effective patient care. However, traditional formats such as SOAP (Subjective, Objective, Assessment, and Plan) and BIRP (Behavior, Intervention, Response, and Plan) often fail to capture the nuanced complexities of therapeutic sessions, as they primarily focus on surface-level details and lack a comprehensive understanding of the patient’s history, mental status, and therapeutic process. While recent advances in Artificial Intelligence (AI) and Large Language Models (LLMs) show promise in clinical documentation, their application in psychotherapy note summarisation remains unexplored. We present iCARE ( i dentifiers, C hief Concerns and Clinical History, A ssessment and Analysis, R isk and Crisis, E ngagement and Next Steps), a comprehensive framework for AI-assisted psychotherapy documentation that addresses these limitations. iCARE comprises of 17 clinically relevant aspects, developed collaboratively with mental health professionals, and aligned with established guidelines. We further introduce PATH ( P sychotherapy A spects and T reatment H istory summary), a novel dataset of annotated therapy sessions. Through extensive benchmarking with 11 LLMs, including both open and closed-source models, we evaluate their performance across different note-taking aspects using automatic and human evaluation metrics. Our results show that closed-source models like Gemini Pro and GPT4o-mini excel in various aspects, with Gemini Pro achieving superior human evaluation scores. Notably, all models struggle with temporal reasoning and complex therapeutic interpretations. The findings suggest that current LLMs can assist in basic documentation but require improvements in handling longitudinal therapeutic relationships and aspects that require deeper clinical understanding and interpretative reasoning. This work advances mental health care documentation while emphasising the need for continued clinical expertise in psychotherapy note summarisation.