Introduction

The juvenile justice system serves a large population with high rates of unmet mental health needs.1,2 Youth in these settings often experience various forms of trauma, stigma, mistrust of institutional systems, and barriers to accessing high-quality, evidence-based care.3 These challenges are compounded by broader social inequities, including disparities based on race, socioeconomic status, and caregiver and family factors.4 Mental health providers in these settings face the dual challenge of addressing individual needs while navigating the limitations inherent to providing care to youth in the justice system.

Prior treatment standards have been established regarding the structural elements of mental health services for justice-involved youth, focusing on systemic aspects such as interface with the legal system, resource allocation, interagency collaboration, and the implementation of evidence-based practices.5 Such standards have significantly contributed to improving the organizational framework of juvenile justice mental health services, but typically stop short of recommendations at the individual patient level. Similarly, while numerous publications have characterized the barriers to treatment participation in this setting, the literature suggests a gap in discrete, positive strategies to enhance therapeutic engagement.6

This Clinical Perspective builds on existing treatment standards by proposing a complementary framework specifically designed to enhance therapeutic engagement. By focusing on voluntary treatment, transparency, collaboration, informed consent, and the acknowledgment of treatment limitations, treatment is improved for the patient and the provider (see Table 1). This framework offers actionable strategies to strengthen the therapeutic alliance and foster empowerment at the individual, family, and community level, thereby improving provider experiences and patient outcomes in juvenile justice mental health care. This dual approach—integrating structural reforms with enhanced therapeutic practices—is essential for creating more effective and equitable mental health care systems within the juvenile justice context.

Table 1.Sample Provider Statements Incorporating Framework Principles
Voluntary participation
“Everything we do today is voluntary. At any time, you can tell me you want to stop or leave. You can also choose to not answer any of my questions. It’s up to you if you want to work with my team for therapy or take medication.”
Transparency
“My team and I are not part of Child Protective Services or the court system. Whatever we discuss is protected health information and I’m not sharing it with Child Protective Services or the court unless I have you and your guardian’s permission.”
Collaboration
“My job today is to hear more about you and if I think any mental health diagnosis describes some of what you’re dealing with, I will tell you what I think and why. Then we can discuss together whether you think that diagnosis fits your experience.”
Informed assent and consent
“If I think there are any medications which can help you, I’ll give you my recommendations and what I think are the potential pros and cons of that medication. I’ll also have a similar conversation with your guardian. After that, we can all work together to figure out what treatment is best for you.”
Acknowledgment of treatment limitations
“Mental health means that there are a lot of things that are good medicine which aren’t medication. Getting through your legal case, going back home, sleeping right, eating right, being around the right people—these are all good for your mental health. In some cases, medication can also be part of the solution.”

Best Practices for Therapeutic Engagement

Voluntary Participation

Engagement improves when youth and their families know participation is voluntary rather than mandatory or coerced. This is a general guiding principle for working with adolescents but is even more relevant for justice-involved youth that have experienced institutional and interpersonal coercion in environments inherently defined by a lack of autonomy. Clinicians should emphasize choice, creating a foundation of trust and collaboration. Youth and their legal guardians should be explicitly empowered to decline services at every level, whether it be deferring completion of the intake process, refusing to answer a question in treatment, or declining to accept medication recommendations.

Transparency

Clear and honest communication fosters trust. Clinicians should provide detailed explanations of their individual role and responsibility as well as the mental health team’s larger place in relation to the courts and the agencies that govern the relevant treatment setting. It is especially important for providers to clearly label the purpose of each clinical encounter and conclude with explicit next steps early in treatment. Care should be taken to distinguish mental health service from other components of the juvenile justice environment, such as legal case management, nonpsychiatric medical care, acute behavioral management, and the forensic mental health clinicians who provide evaluations for the court or legal team.

Collaboration

Youth must be treated as active and knowledgeable partners in their care. This includes soliciting their input throughout intake, assessment, and treatment, validating their experiences prior to and during their admission, and empowering them to take ownership of their mental health by assuming the best of their actions, exercising a nonjudgmental stance whenever possible. Diagnoses and treatment options should be framed as expert opinion and recommendations, respectively, and not presented as definitive or comprehensive.

Clinicians must ensure that youth and their legal guardians clearly understand their rights, the nature of and indications for treatment, reasonable alternatives, and associated risks or benefits. This process not only fulfills ethical obligations but also reinforces the therapeutic alliance. Given the compounded vulnerabilities of incarcerated minors, providers’ obligation to uphold principles of informed assent and consent are even more heightened and indispensable than in typical clinical practice.7

Acknowledgment of Treatment Limitations

Many youth and their families have little prior contact with mental health services prior to juvenile justice involvement. Many of those who have had prior contact with providers have had negative experiences or poor outcomes. Compounding this, many of the acute and chronic stressors faced by these families are outside the direct scope of mental health treatment, from the relevant delinquency or criminal case to broader structural challenges such as poverty and racism that disproportionately affect justice-involved youth. To maintain credibility, providers must acknowledge that mental health diagnosis represents only one paradigm for describing the challenges in patients’ lived experience, and mental health treatment is only one mechanism of ameliorating these challenges. As an extension of this, discussions of the potential benefits of treatment including psychotherapy and medication must be framed specifically and realistically with clear acknowledgment of the limitations of treatment.

Discussion

Consideration of this framework must be coupled with broader advocacy for structural reform that ensures equitable, evidence-based care in juvenile justice settings. Despite the adoption of trauma-informed and culturally competent practices, treatment environments remain constrained by limited resources, institutional mistrust, and systemic inequities.3,5 The impact of this approach may be magnified in rural practice environments where providers and systems often have less structural support compared to urban contexts. This framework complements existing approaches such as motivational interviewing, shared decision-making, and strengths-based and trauma-informed care. Emphasizing voluntary participation and transparency supports trauma-informed goals of safety and empowerment, while collaboration aligns with shared decision-making which improves engagement and adherence among justice-involved youth.2,4 Implementation requires institutional support, including training and structural flexibility that allows clinicians to meaningfully engage patients. It is especially essential that treatment teams operate independently from the court and detention systems, as any efforts to develop a therapeutic relationship will be compromised if the patient and family have valid concerns regarding dual agency. Without these considerations, especially in fast-paced or punitive environments, clinicians may be unable to uphold core principles like autonomy and collaboration.3

Barriers such as youth mistrust, internalized stigma, and clinician burnout persist. Yet even small shifts in provider communication, such as validating resistance or reframing compliance as collaboration, can improve engagement.6 Future research should examine how this framework can be practically applied and evaluated. Qualitative studies may illuminate the relational skills that foster trust, while longitudinal research could assess its impact on outcomes such as symptom improvement and reduced recidivism.5 This approach may also benefit other high-risk settings where engagement is often compromised by systemic challenges. While primarily developed through in-person treatment, the best practices discussed here remain relevant and beneficial when working with patients or families via phone or in telehealth settings. Ultimately, therapeutic engagement with justice-involved youth is both a clinical goal and a moral imperative. Providing care that affirms youth agency, validates lived experiences, and acknowledges the limitations of psychiatry in the face of structural adversity is essential to delivering equitable and compassionate mental health care.

Conclusion

Justice-involved youth deserve equitable access to effective and compassionate mental health care. By adopting a framework that prioritizes voluntary participation, transparency, collaboration, and acknowledgment of treatment limitations, clinicians and mental health teams can enhance therapeutic engagement and improve outcomes.

Plain Language Summary

Young people in the justice system can have a particularly hard time getting mental health treatment. This article provides an approach for mental health providers to better meet the needs of justice-involved youth. This approach uses voluntary participation, transparency, collaboration, informed consent, and acknowledgment of the limitations of treatment to provide better care. Using the skills in this article will help providers feel better about their work and improve the experience of their patients.

Contributions

Conceptualization: Eric Whitney (Lead), Klara Wichterle (Supporting), James Dinulos (Supporting). Supervision: Eric Whitney (Lead). Writing – review & editing: Eric Whitney (Lead), Klara Wichterle (Supporting), James Dinulos (Supporting). Writing – original draft: Eric Whitney (Supporting), Klara Wichterle (Equal), James Dinulos (Equal).

About the Authors

Eric Whitney, MD, MSEd, Department of Child & Adolescent Psychiatry, New York University Grossman School of Medicine, New York, New York, USA.

Klara Wichterle, BA, New York University Grossman School of Medicine, New York, New York, USA.

James Dinulos, BA, New York University Grossman School of Medicine, New York, New York, USA.

Correspondence to:

Eric Whitney, MD, MSEd; email: eric.whitney@nyulangone.org, telephone: 718-688-8219, fax: 334-633-7154.

Funding

The authors have reported no funding for this work.

Disclosures

Dr. Whitney, Ms. Wichterle, and Mr. Dinulos report no biomedical financial interests or potential conflicts of interest.

Acknowledgments

The authors wish to thank Alan C. Wittenberg, MD, of New York University Grossman School of Medicine, for his clinical contributions as the Medical Director of the Bellevue Juvenile Justice Mental Health Service and Tomika Carter, MSW, of New York University Grossman School of Medicine, for her leadership as the Executive Director of the Bellevue Juvenile Justice Mental Health Service. The authors also wish to thank the New York City Administration for Children’s Services (ACS) for their ongoing collaboration with this project.

This article is part of a special Clinical Perspectives series that will shed new and focused light on clinically important topics within child and adolescent psychiatry. The series discusses the care of children and adolescents with psychiatric disorders from a new vantage point, including populations, practices, and clinical topics that may be otherwise overlooked. The series was edited by JAACAP Deputy Editor Lisa R. Fortuna, MD, MPH, MDiv; JAACAP Connect Editor David C. Saunders, MD, PhD; and JAACAP Editor-in-Chief Douglas K. Novins, MD.