"There's longstanding evidence that the most important determinant about what treatment works for people is not the treatment modality itself, but the relationship that the client has with their therapist," says Rochelle Burgess, a professor of Global Mental Health and Social Justice at University College London, who is part of The SHM Foundation's working group. While Burgess is referring to clinical research, we found that the same principle holds across a wide range of settings. The choices that programs make about who delivers support, and how, are not secondary to the intervention. They are central to whether it works.

Adriano de Carvalho Mendes, a young person who received support from Luta pela Paz in Rio de Janeiro, describes what this looks like in practice. The first psychologist he sought care from shared key aspects of his identity (a Black, gay man) and that match transformed the process. "I was able to bring up very delicate issues, and I could see that the person who was assisting me at that moment had the sensitivity that I needed at that time," he says. After the program ended, he continued with the same psychologist, and when he eventually encountered other providers whose approaches didn't fit, the earlier experience had given him the ability to recognize the difference. The relationship gave him an understanding of what quality care felt like and the confidence to seek it out on his own.

Burgess drew on the concept of cultural safety, a framework originating from work with indigenous communities in New Zealand. In this approach, the person receiving care defines what they need to feel safe in the therapeutic relationship. "What are the things that you need in order to feel safe in this care environment, in this relationship, in this treatment modality? You define what makes you safe," she explains. In mental health work, where progress depends on vulnerability and disclosure, a provider who cannot see the person's full reality may not just fail to help but also actively undermine trust in care itself.

Burgess gave the example of a young person arriving in therapy saying their problem is racism, that they live in a racist society, experience racism in the classroom, and see racism as connected to poverty and neighborhood safety. "If a young person is coming with all of this stuff that they connect to their process of being racialized, how do we meet them with love and generosity and care?” she says. “A big part of that would be to say, 'I see that,'" rather than redirecting them to exercises that deny their experience of the world.

Building the relationship before the program begins

This principle also runs through the work of organizations operating far from clinical settings. Anisha Chablani-Medley of Roca, which works with young people affected by violence in Massachusetts and Baltimore, describes a model built around the primacy of relationship. Roca's youth workers make eight to nine contact attempts per young person. Even if they get screamed at and have doors slammed in their faces, they keep showing up. "It's not about them proving to us that they're ready for the program," Chablani-Medley says. "It's about us proving that we'll consistently show up for them."

The relationship has to be authentic. "It can't be this positioned relationship, where I'm here to help you because you are a mess," she says. And it has to involve the worker's own vulnerability. "That authentic relationship is critical to young adults, particularly in their healing process — having someone who's willing to be vulnerable with you when you're asking them to be so vulnerable."

Roca tried a formal 23-session sequential CBT curriculum, but found it didn’t fit into the lives of the young people they work with. So they developed Rewire CBT, a modular approach delivered on street corners and in cars. The clinical content matters, but it works because it is carried by a relationship that has been built over months of persistent contact. The skills that Rewire teaches, such as being present, labeling feelings, and acting on values, are the same skills staff use in their own supervision and processing. The relationship between worker and young person is inseparable from the intervention.

Implications for program design

Across the interviews we conducted, the quality of the relationship between a young person and the adults who lead these programs emerged as a consistent factor in whether support actually results in change. This suggests that decisions about staffing, provider matching, training in foundational relational skills, and flexibility in how and where support is delivered deserve the same attention and investment that program design and evidence-building typically receive. For funders and program leaders, attending to the conditions that allow these relationships to form and persist may be one of the most direct ways to strengthen the outcomes of the programs they already support.