Multi-Objective Aligned Small Language Model Framework for SUD Patient Dialogue Generation

Substance Use Disorder (SUD) counseling requires patient responses that reflect underlying cognitive states such as beliefs, coping strategies, and readiness for change. Although large language models (LLMs) can generate fluent text, they often fail to produce cognitively coherent and clinically realistic patient behavior, especially under ethical and data-scarce clinical settings. Moreover, deploying frontier-scale LLMs in healthcare applications presents practical challenges including high computational cost, latency, privacy concerns, and limited deployability in resource-constrained environments, motivating the need for cognitively aligned small language models (SLMs). We propose a cognitively grounded framework for SUD patient dialogue generation that explicitly models and aligns latent cognitive components with patient histories and counselor questions. Our pipeline consists of two stages: cognitive component detection and cognitive component-aligned dialogue generation. To enable effective learning with smaller models, we combine knowledge distillation from high-capacity teacher models, preference optimization from human-annotations, and attention-guided reward shaping. Extensive evaluations using automatic scores like BERTScore, ROUGE, METEOR and BLEU, and LLM-as-judge hit-metrics against both human and teacher-model references show that cognitively informed fine-tuning substantially improves cognitive realization and alignment over a generic instruction-tuned baselines and mental health domain specific SLMs, with particularly strong gains for open-ended cognitive components.