It is sobering to consider that the majority of occupational therapy students have fieldwork experiences in mental health and physical disabilities and yet less than 15% choose practice in mental health. How can one account for the limited interest of students in mental health in a field that strongly espouses a holistic approach to patients? This article explores and reviews potential parameters affecting the specialty choice of mental health, to encourage further clarification of problems, identify areas for research and foster creative problem solving. Several theoretical lenses will be suggested to promote clearer focus on conceptual approaches to understanding practice preferences. The occupational therapy literature will be reviewed focusing on personality characteristics, learning style, academic and fieldwork experiences and job satisfaction. Additional perspectives including specialization, reality shock, and discontinuity between the academic and clinical phases of professional training are offered from the literature on professional socialization as viable models for understanding this phenomenon. To reverse the trend of declining numbers of practitioners in mental health, recommendations are made for recruitment, academic and clinical education and practice.