Recruitment is your first retention strategy. The resignation letter is usually the last data point in a much longer story.
Recruitment is your first retention strategy. By the time someone hands in a resignation, the organization has probably been receiving feedback for months.
There's a pretty predictable routine that happens when an employee leaves a behavioral health organization.
Leadership expresses disappointment, sometimes genuine surprise, and begins discussing how to fill the position as quickly as possible. The employee's responsibilities are redistributed among the people who remain, a familiar job description gets pulled from an old folder, and HR starts reviewing applications.
Eventually, someone is hired, the schedule is covered again, and everyone moves on.
At least until the replacement leaves six months later, at which point leadership begins another thoughtful discussion about how difficult it has become to find reliable employees.
Apparently, nobody wants to work anymore.
I've spent enough time in behavioral health operations to recognize how easily organizations fall into this cycle. And while I understand that recruiting qualified employees is genuinely difficult, particularly in our industry, I think we're often far too quick to treat turnover as a hiring problem without considering what the organization might be contributing to it.
Because employees rarely decide to leave in a single moment.
More often, there's a much longer story leading up to that resignation. Maybe the workload gradually became unreasonable, or the position evolved into something entirely different from what was originally discussed. Perhaps expectations were never clearly defined, supervision was inconsistent, or commitments made by leadership repeatedly failed to materialize.
Sometimes employees leave because they've found a better opportunity, their circumstances have changed, or the role simply isn't the right fit. Not every resignation represents organizational failure, and pretending otherwise wouldn't be particularly useful.
But when turnover becomes a pattern, particularly within certain departments, positions, or leadership teams, I think we need to become considerably more curious about what's happening.
Because employee turnover isn't simply an HR metric.
It's information about how an organization operates, how its employees experience that operation, and whether the systems designed to support them are actually working.
And by the time someone hands in a resignation, the organization may have already missed several opportunities to do something about it.
The Real Cost of Losing an Employee Goes Well Beyond Recruiting Their Replacement
When organizations discuss the financial impact of employee turnover, the conversation usually begins with recruitment expenses.
And those costs are certainly real. Job postings, recruiting fees, background checks, credential verification, interviews, onboarding, and training all require time and money.
But in behavioral health, I would argue that some of the most significant costs are the ones that never appear as an obvious line item on a financial report.
Consider what happens when a therapist leaves an outpatient practice.
Depending on the circumstances, patients may need to be reassigned, appointments may be canceled, and referral availability may decrease. Some patients might be willing to transition to another clinician, while others may struggle with the disruption or choose not to continue treatment.
Meanwhile, the organization may lose billable capacity while searching for a replacement, and even after someone is hired, insurance credentialing and enrollment can delay the ability to bill certain payers.
The position might technically be filled, but that doesn't necessarily mean the practice has immediately recovered its previous capacity or revenue.
In residential and inpatient environments, the consequences can be even more complicated.
When an experienced direct-care employee, nurse, technician, or clinical supervisor leaves, the responsibilities don't disappear. They get redistributed to the employees who remain, often without much consideration for whether those individuals already have enough work to do.
Someone covers another shift. A supervisor takes on an additional caseload. Documentation gets pushed into overtime. Training responsibilities fall to the same experienced employees who are already compensating for the vacancy.
And because the team generally cares about the patients, they figure out how to make it work.
At least for a while.
This is where turnover can become particularly expensive, because one departure can create the conditions that eventually contribute to another.
The employees who remain become overextended. The organization spends money on overtime or temporary coverage. Supervisors have less time to provide meaningful support, and the overall work environment becomes increasingly reactive.
Then another employee leaves, and leadership finds itself right back where it started.
There's also the time required to bring a new employee up to speed.
Even experienced clinicians and operational professionals need time to learn an organization's patient population, documentation expectations, EHR, payer requirements, policies, communication processes, and clinical workflows.
And, of course, there's always the collection of unwritten procedures that everyone apparently knows but nobody thought to include in orientation.
During that period, the new employee may not be functioning at full capacity, while supervisors and coworkers spend time training, reviewing work, answering questions, and correcting mistakes.
That time is necessary, but it isn't free.
Neither is the leadership time spent repeatedly recruiting and replacing employees.
Every hour a clinical director spends interviewing candidates, coordinating coverage, or resolving problems associated with a vacancy is an hour that can't be spent on supervision, program development, quality improvement, or other responsibilities.
Eventually, the cost of turnover begins affecting areas of the organization that seem entirely unrelated to staffing.
And perhaps most importantly, there's the impact on patients.
Behavioral health treatment depends heavily on trust, relationships, and continuity. When a clinician leaves, patients may have to establish a new therapeutic relationship, repeat difficult personal histories, adjust their schedules, or navigate a transition they didn't choose.
Even when those transitions are handled thoughtfully, they require coordination and clinical judgment.
Simply telling someone that their therapist no longer works there but another provider happens to have an opening Thursday isn't necessarily a continuity-of-care plan.
It's a scheduling solution.
Those two things aren't always interchangeable.
I also think organizations underestimate the cultural cost of turnover. Employees pay attention to how their coworkers are treated when they leave, whether concerns are acknowledged, and whether leadership makes any meaningful effort to address the circumstances surrounding a departure.
When employees repeatedly watch strong colleagues leave without anything changing, it sends a message about what the organization is willing to tolerate.
Eventually, that message becomes part of the culture.
And potentially part of the organization's reputation as an employer.
Turnover Numbers Matter, but Understanding the Pattern Matters More
One thing I encourage organizations to do is stop looking at turnover as a single percentage.
Knowing that a program experienced 20% turnover during a particular period is useful, but it doesn't tell leadership nearly enough to understand what's actually happening.
If an organization has ten employees and two leave, that's a 20% turnover rate. But were those departures voluntary? Did both employees work in the same department? Did they report to the same supervisor? Were they experienced team members or employees who left during their first few weeks?
And perhaps more importantly, did anyone recognize warning signs before they resigned?
Those details change the conversation considerably.
I think it's particularly important to distinguish between employees who voluntarily leave and those who are terminated, as well as between departures that represent a significant loss to the organization and those that may ultimately improve team functioning or patient safety.
Early turnover deserves special attention because it often reveals something about the recruitment or onboarding process.
If an employee leaves within the first 30, 60, or 90 days, it's worth examining whether the role was accurately represented, whether expectations were clear, and whether the employee received the training and support necessary to succeed.
Similarly, if the same position repeatedly becomes vacant, I would be hesitant to conclude that the organization has simply experienced an extraordinary streak of disappointing candidates.
At some point, we should probably consider whether the position itself is contributing to the problem.
The financial implications deserve a more thoughtful approach, too.
There are plenty of articles claiming that replacing an employee costs a particular percentage of their annual salary. Those estimates can be useful for illustrating the general problem, but actual costs vary significantly depending on the position, market, organization, and services provided.
A clinical supervisor leaving a residential program creates different consequences than an administrative employee leaving an outpatient practice. Both departures matter, but their operational and financial effects won't necessarily look the same.
Rather than borrowing an alarming national statistic and presenting it as fact for every position, organizations would benefit from examining their actual recruitment expenses, vacancy duration, lost productivity, training requirements, overtime, and changes in clinical capacity.
Some consequences may be difficult to quantify financially, including disruption to patient relationships or the effect on employee morale.
That doesn't make them irrelevant.
The purpose of analyzing turnover shouldn't be to produce an impressive number for a leadership presentation. It should be to understand whether the organization is spending more money repeatedly replacing employees than it would cost to address the conditions contributing to their departure.
And that's an especially important question in behavioral health, where qualified employees aren't always easy to find.
A 2025 federal workforce brief from the Health Resources and Services Administration reported that approximately 40% of the U.S. population lived in a designated Mental Health Professional Shortage Area as of December 2, 2025. HRSA also projected substantial future shortages across several behavioral health professions.
That tells us something important about the environment in which organizations are recruiting.
We can't control the national workforce shortage.
But we can certainly examine whether our own practices are making it unnecessarily difficult to attract, develop, and retain qualified people.
Which brings me to something I think deserves far more attention than it typically receives.
Recruitment Is Your First Retention Strategy
I think organizations often make the mistake of treating recruitment and retention as two separate functions.
Recruitment is about finding someone to fill a position. Retention is about convincing them to stay once they've been hired.
But the experience that determines whether someone will remain with an organization begins long before their first day.
It starts with how the position is designed, how the organization communicates with candidates, how accurately the work is described, and whether leadership actually understands what success in the role should look like.
And I would argue that a considerable amount of preventable turnover begins right there.
I've seen organizations become so focused on filling a vacancy that they neglect to examine whether the position they're recruiting for is actually structured in a way that allows someone to succeed.
A department needs help, so leadership pulls an old job description, adds a few responsibilities, and posts the opening.
Sometimes the description has become such an impressive collection of unrelated expectations that it would require three people and a very flexible understanding of the number of hours in a day.
But apparently, the ideal candidate will be adaptable.
I have nothing against flexibility. It's essential in behavioral health.
What concerns me is when flexibility becomes a convenient substitute for clearly defined responsibilities, adequate staffing, and realistic expectations.
Before recruiting, leadership should understand what the position is intended to accomplish, what responsibilities belong to it, how performance will be evaluated, and what authority the employee will have to make decisions.
Compensation should also reflect the actual expectations of the role, rather than a title that may no longer accurately describe the work.
And if three members of the leadership team provide three different explanations of what the new employee will be responsible for, that might be worth resolving before inviting candidates to interview.
Because hiring someone into a poorly defined position doesn't make the ambiguity disappear.
It simply transfers the confusion to a new employee.
I also think organizations need to become more comfortable providing realistic descriptions of the work during recruitment.
Behavioral health is demanding. Patients have complex needs, unexpected situations arise, and employees sometimes have to navigate emotionally difficult circumstances.
There's no reason to pretend otherwise.
A candidate considering a clinical position should understand the population being served, typical caseload expectations, documentation requirements, schedule, supervision structure, and any on-call or crisis responsibilities.
Someone interviewing for an operational or leadership position should understand the scope of their authority, current organizational challenges, reporting relationships, and what they'll be expected to accomplish.
That includes discussing areas where the organization is still developing or experiencing difficulty.
I understand the temptation to present everything in the most favorable possible light. Organizations want strong candidates, particularly when vacancies have been difficult to fill.
But describing a chronically understaffed, poorly organized department as an exciting, fast-paced environment isn't necessarily doing anyone a favor.
A candidate who decides a position isn't the right fit after receiving an accurate description hasn't created a recruitment failure.
They've prevented a potentially expensive and frustrating mismatch.
And I think organizations would save themselves considerable time and money if they viewed those decisions differently.
A Good Interview Should Tell You More Than Whether You Like Someone
Another area where I think recruitment frequently falls short is how candidates are evaluated.
There's something to be said for a comfortable interview. Communication matters, and the ability to connect with coworkers, patients, and leadership is certainly relevant.
But I've seen hiring decisions place far too much emphasis on whether everyone enjoyed the conversation.
The candidate is personable, the interview flows naturally, someone discovers they have a mutual connection, and by the end of the meeting, everyone feels pretty good about the person.
Wonderful.
But can they actually do the job?
That's a different question.
A structured interview process can help organizations evaluate candidates more consistently by identifying the competencies required for the position and asking questions designed to assess them.
The U.S. Office of Personnel Management's guidance on structured interviews emphasizes using a job analysis, consistent job-related questions, and common rating criteria to improve fairness and reduce subjectivity.
That doesn't mean interviews need to feel robotic or that every interaction should be reduced to a numerical score.
It means organizations should be intentional about what they're trying to learn.
For a clinical role, that might involve asking candidates to describe how they've handled a challenging treatment situation, maintained professional boundaries, responded to feedback, or navigated a disagreement involving patient care.
For an operational role, it might involve discussing how someone prioritizes competing responsibilities, manages conflict, addresses performance concerns, or approaches a process that isn't working.
I tend to be particularly interested in understanding how people think.
Not just what they've accomplished, but how they approached a problem, what information they considered, why they made a particular decision, and what they learned from the result.
In some situations, a brief, relevant work sample can provide additional insight. A candidate might be asked to evaluate a de-identified scheduling problem, explain how they would respond to a difficult operational scenario, or discuss how they'd approach their first month in a leadership position.
The exercise should be reasonable and directly related to the position.
It should not involve asking someone to complete an entire consulting project for free under the charming description of a hiring assessment.
The goal is to understand the candidate's judgment and capabilities, not obtain several hours of unpaid work from someone who hasn't even received an offer.
And while we're discussing recruitment, I think organizations need to pay more attention to how they treat candidates throughout the process.
Communication matters. Transparency matters. Following through matters.
If a candidate completes several interviews, receives enthusiastic feedback, and is told to expect an update, disappearing for six weeks without communication isn't exactly demonstrating an impressive organizational culture.
I realize hiring timelines change, competing priorities arise, and decisions sometimes take longer than expected.
But people generally understand delays when they're communicated honestly.
What becomes frustrating is the complete absence of communication, particularly when organizations have repeatedly emphasized how much they value people.
Candidates are evaluating the organization just as much as the organization is evaluating them.
And sometimes the recruitment process tells them everything they need to know.
Onboarding Is Where the Recruitment Promises Get Tested
Let's assume the organization has found a qualified candidate, made a fair offer, and successfully brought them on board.
At that point, the hard part isn't necessarily over.
Because the first several weeks of employment are when the expectations established during recruitment either begin to feel accurate or fall apart.
I think most organizations understand that onboarding is important, but there can be a significant difference between completing required orientation paperwork and actually preparing someone to perform their job.
New employees need more than a stack of policies, login credentials, and a cheerful introduction to the break room.
They need to understand the systems they'll use, the workflows they'll follow, the people they'll collaborate with, and the standards against which their performance will be evaluated.
In behavioral health, that also means appropriate training related to patient safety, clinical documentation, escalation procedures, confidentiality, and the specific needs of the population being served.
And those things take time.
A therapist joining an outpatient practice may need support understanding the EHR, documentation expectations, payer requirements, scheduling processes, and clinical consultation resources.
A direct-care employee in a residential program needs meaningful preparation for the environment, patient population, behavioral expectations, crisis procedures, and the practical realities of working with the team.
A new manager needs clarity about decision-making authority, performance expectations, operational priorities, and how leadership expects concerns to be escalated.
None of those employees should be expected to become fully competent simply because someone gave them access to the appropriate software.
Yet I've seen onboarding processes that essentially consist of a few shadow shifts, several documents to acknowledge, and an assumption that the employee will ask questions if they need help.
Then, when the employee struggles, leadership begins wondering whether they were the right hire.
Perhaps.
But I'd also be curious about what training they actually received.
Strong onboarding should include defined expectations, appropriate supervision, opportunities to observe and practice, and regular conversations about progress.
I particularly like the idea of establishing meaningful 30-, 60-, and 90-day expectations, not because every employee should follow an identical development timeline, but because it creates opportunities to identify problems before they become performance failures.
New employees should know what they're expected to learn, what support is available, and how leadership will determine whether they're progressing appropriately.
They should also feel comfortable explaining when something isn't clear or when the reality of the position differs from what they were told during recruitment.
Because giving someone a full caseload, two working passwords, and a calendar invitation to check in sometime next month isn't really an onboarding strategy.
It's organizational hide-and-seek.
And it shouldn't surprise us when the employee eventually decides they would prefer to work somewhere with a little more structure.
When the Same People Keep Leaving, Maybe We Should Look at the Organization
This is the part of the turnover conversation that I think becomes especially uncomfortable.
Because once organizations begin examining patterns rather than individual departures, the findings may challenge some longstanding assumptions about why employees leave.
Take workload, for example.
Behavioral health organizations frequently establish productivity expectations based on the number of patients a clinician should see, the number of groups a staff member should facilitate, or the amount of work a department should complete.
But those expectations don't always account for the time required to document services, coordinate care, attend meetings, provide supervision, respond to crises, or handle administrative responsibilities.
And if the work consistently requires more hours than the position reasonably contains, employees are left with a limited number of options.
They can work additional hours, delay tasks, sacrifice quality, or eventually decide the job is no longer sustainable.
None of those should be particularly surprising outcomes.
The U.S. Surgeon General's guidance on health worker burnout identifies excessive workloads, administrative burdens, limited control over scheduling, and inadequate organizational support as important contributors to burnout.
The guidance emphasizes that burnout is not simply an individual resilience problem. Organizational conditions matter.
And I think that's something healthcare leaders need to take more seriously.
It's easy to encourage employees to practice self-care, establish boundaries, and develop healthy coping strategies.
Those are all worthwhile things.
But if the organization has created a workload that cannot realistically be completed within the available time, another reminder to practice mindfulness probably isn't going to resolve the underlying issue.
There's only so much a meditation app can accomplish when someone is covering two positions and hasn't taken a lunch break all week.
Management practices are another area worth examining.
Employees need clarity about expectations, access to feedback, and confidence that concerns will be handled fairly.
When managers avoid difficult conversations, problems tend to grow. When feedback is inconsistent or primarily critical, employees may become increasingly uncertain about what success looks like.
And when leadership responds defensively or punitively to disagreement, people learn very quickly which concerns are safe to raise.
Eventually, they stop raising them.
Sometimes the first truly honest conversation an organization has with an employee is during the exit interview.
Which is unfortunate, considering that's usually the point when the employee has already decided the organization is no longer worth trying to change.
Compensation also deserves an honest place in this discussion.
I understand that money isn't the only factor influencing employee retention. People care about their coworkers, patients, schedules, leadership, professional development, and whether they find the work meaningful.
But compensation absolutely matters.
And I find it interesting how often organizations emphasize purpose, culture, and appreciation when employees raise concerns about pay.
Those things are important, but they aren't substitutes for compensation that reflects the responsibilities, experience, and expectations of the position.
Neither are promises that never seem to materialize.
An employee may be willing to tolerate a temporary financial limitation when leadership is transparent about the circumstances and follows through on its commitments.
But when employees repeatedly hear that compensation adjustments, advancement opportunities, or additional support are coming, only to watch the deadlines pass without action, the issue becomes bigger than money.
It becomes a question of trust.
And once employees stop believing that leadership's commitments mean anything, even reasonable explanations become difficult to accept.
Praise is lovely.
Unfortunately, most mortgage companies remain stubbornly unwilling to accept it as payment.
Professional growth matters, too.
Not every capable employee wants to become a manager, and advancement shouldn't always mean moving into a leadership position. Some people want to deepen their clinical expertise, pursue specialized training, take on more responsibility within their discipline, or develop new skills.
Others want greater autonomy, mentorship, schedule flexibility, or opportunities to contribute to program development.
A strong organization should understand what growth means to its employees rather than assuming everyone is motivated by the same things.
Because when talented employees recognize that their responsibilities will continue increasing while their opportunities remain unchanged, they may eventually seek that development elsewhere.
And I don't think we should be particularly shocked when they do.
Sometimes Turnover Is Necessary, and That's Worth Acknowledging
I don't want this discussion to imply that every employee who leaves should have been retained or that organizations should avoid making difficult employment decisions.
There are absolutely situations where separation is appropriate.
Employees can fail to meet essential expectations, disregard policies, violate professional standards, create safety concerns, or demonstrate that they're not suited to the responsibilities of the position.
In those situations, retaining someone simply to protect a turnover statistic can create much more serious problems.
But I think the process still matters.
When circumstances reasonably allow, employees should understand what is expected of them, where their performance is falling short, what needs to change, and what support is available.
Accountability should be clear, consistent, and grounded in actual performance.
And when an organization determines that someone isn't able or willing to meet the necessary standard, the decision should be handled professionally and fairly.
Not every situation allows for a lengthy improvement process, particularly when serious safety or ethical concerns are involved.
But "we never explained the problem because they should have known" isn't a particularly compelling performance-management strategy.
There's also an important distinction between an employee being unsuccessful in a well-supported position and an organization repeatedly placing people in a role that hasn't been adequately designed.
If multiple employees struggle under the same conditions, I'd want to understand those conditions before concluding that every individual was simply a poor fit.
Sometimes the employee is the problem.
Sometimes the system is.
And sometimes both are contributing.
Strong leadership requires enough curiosity and objectivity to distinguish between them.
Maybe We Should Start Having Stay Interviews Instead of Waiting for Exit Interviews
One of the more practical changes I think organizations could make is spending less time waiting for employees to explain why they're leaving and more time asking what would help them want to stay.
Exit interviews can be useful, but they're limited by timing.
By the time someone has accepted another position, negotiated compensation, and made the decision to leave, the organization may have very little opportunity to change the outcome.
And depending on the employee's experience, they may not be particularly interested in providing detailed feedback.
That's understandable.
Why spend another hour explaining problems you've already raised several times to the people who didn't address them?
Stay interviews offer a different opportunity.
Instead of waiting for a resignation, managers can have intentional conversations with current employees about what's working, what's becoming difficult, and what might influence their decision to remain with the organization.
I think these conversations can be especially valuable when they're approached with genuine curiosity rather than as another employee-engagement exercise.
Ask people what they enjoy about their work and what makes it meaningful. Find out which responsibilities have become difficult to manage, whether they feel supported, and what barriers interfere with their ability to do their jobs well.
Ask whether expectations are clear, whether the organization has followed through on its commitments, and what opportunities for development would matter to them.
And perhaps most importantly, be willing to hear an answer that isn't particularly flattering.
Because inviting employees to provide honest feedback and then defending every organizational decision in real time isn't likely to encourage much transparency.
Neither is asking for suggestions, making no changes, and congratulating leadership six months later for having established an employee-feedback initiative.
The conversation only becomes valuable when something happens as a result.
That doesn't mean an organization can or should accommodate every request. Financial limitations exist, competing priorities are real, and sometimes employees want things the organization simply cannot provide.
But leadership can still communicate honestly, explain decisions, and demonstrate that concerns were taken seriously.
And when patterns appear across multiple employees, those patterns deserve attention.
If several people describe the same workload problem, it may be worth examining how the position is structured.
If employees repeatedly express confusion about expectations, perhaps management needs to communicate more clearly.
And if multiple people are concerned about commitments that haven't been honored, leadership should probably spend less time explaining why employees are disengaged and more time considering how its own actions have contributed to that disengagement.
None of this requires an elaborate employee survey platform.
It requires intentional conversations, a willingness to listen, and the discipline to follow through.
The Actual Useful Truth
I've spent a significant portion of my career working with behavioral health teams, building operational systems, establishing performance expectations, improving workflows, and trying to understand why organizations experience the same problems over and over again.
And one thing I've become increasingly convinced of is that employee turnover should never be examined in isolation.
Recruitment, onboarding, compensation, supervision, workload, organizational culture, and leadership accountability are all connected.
When those systems work together, employees have a much better opportunity to succeed.
When they don't, the organization can find itself continually recruiting replacements for positions that were never structured to support the people filling them.
Because I don't think we can solve turnover simply by becoming better at posting jobs.
We need to understand why employees join, what they experience once they're there, and what ultimately influences their decision to stay or leave.
That means tracking meaningful workforce information alongside clinical, operational, and financial performance.
I'd want to know not only how many employees are leaving, but when they're leaving, which positions are most affected, how long vacancies remain open, and how much time it takes new employees to become fully competent.
I'd want to understand whether vacancies are reducing patient access, increasing overtime, delaying program development, or affecting employee morale.
And I'd be particularly interested in what employees have been telling us along the way.
Because turnover data doesn't become useful simply because it appears on a leadership dashboard.
It becomes useful when the organization is willing to examine what the information means and make decisions based on what it learns.
I think that's ultimately the distinction between an organization that manages turnover and one that simply reacts to it.
One is trying to understand and improve the conditions influencing employee retention.
The other is repeatedly replacing people and hoping the next person will somehow produce a different result under the same circumstances.
And while hope is certainly an admirable quality in behavioral health, I'm not convinced it should be the foundation of a workforce strategy.
The reality is that even well-managed organizations will experience turnover. Employees will relocate, change careers, pursue new opportunities, and occasionally discover that a particular job simply isn't right for them.
That's normal.
What's worth examining is whether an organization is repeatedly losing capable employees for reasons it could reasonably address.
If the same concerns keep appearing, the same positions keep becoming vacant, and the same recruitment process keeps producing the same disappointing results, perhaps the organization needs to stop asking why it can't find good employees.
Maybe the more useful question is whether we've created an environment where good employees can actually succeed and want to stay.
Because by the time someone hands in a resignation, the organization has often been receiving feedback for months.
The resignation is simply the point at which the employee has decided they're finished waiting for something to change.
And if we're genuinely interested in retention, I think we should probably start paying attention long before that happens.
