This interview study with special education teachers in rural and urban school divisions within Virginia, USA, reports instructional strategies that support outcomes for students with social emotional mental health (SEMH) needs. Evidence-based strategies from the interviews are delineated for teachers who work with this highly vulnerable population. K-12 teacher-student relationships (TSRs) and four relational phases -- appraisal, testing, agreement, and planning -- were analyzed. Strategies for influencing students socially, academically, and behaviorally were also identified. Research questions probed (a) the role of TSRs for students with risk factors and (b) strategies for achieving desirable results in SEMH contexts. TSRs were examined relative to supports and risks associated with students' development and success. A literature synthesis of strategies and models for advancing knowledge is included. The article offers insight into what teachers do in actual situations to foster student growth and outcomes.