From Clinical Judgment to Checkable Rules: Clinician-Led Guardrails for Mental-Health Chatbots

Abstract

Large language models (LLMs) deployed in mental-health contexts can be evaluated for safety failures, but the resulting judgments are often difficult to inspect or explain. Common approaches to improving safety rely on prompt engineering, LLM-as-a-Judge, and Constitutional AI. In this work, we describe a clinician-led alternative in which two clinicians define, finalize, and adjudicate the four safety checks of a rule base, which is formally verified for internal consistency and applied as a guardrail over LLM outputs. Here and in the title, clinician-led refers to this rule base, not to the fact extractor or the uncertainty default, which are ours. Every verdict of the resulting verification layer is recomputable from a named rule and sixteen facts. Against an LLM judge matched in model, revision, quantization, rule text, and decoding but without the layer's computed 988/911 fact, the largest disagreement class, the satisfied-rule class, is structured: the Llama-3.3-70B judge, on its primary prompt, demands a crisis resource from 55 of the 65 replies (84.6%) that already contain one, while the same model, asked as a fact extractor, reports a recognized resource present on 54 of the 55. The verification layer never raises that demand, by construction. We report with equal prominence where this judge is stronger: fewer false crisis alarms on the one reference-scored check. We also report the measured cost (a specification revision raised block-class outcomes on held-out boundary prompts of an over-refusal benchmark from 6.0% to 16.0%, chiefly by changing fact extraction), the clinicians' decision to keep our uncertainty default, and the analysis of the result. The contribution is not a safer verdict. It is a guardrail whose disagreements with the judge localize to named rules and facts and whose measured costs trace to named facts and the uncertainty default.