We have seen the extraordinary growth of managed care, which may be defined as various "arrangements that regulate the utilization, site, and costs of services .... [in which] the nature and length of mental health treatment is determined partially by parties (insurers and reviewers) other than the clinician and patient/client" (Hoyt, 1995a, p. 1 ). From humble beginnings in the first years after 1900 involving collectives of loggers in the Northwest and Cuban-emigre cigar makers in Florida, through the nascency of the Laos-Atkins Clinic in Los Angeles during the 1920s and the advent of the Kaiser Permanente medical program in the late 1930s and 1940s (Henricks, 1993; Smillie, 1991 ), early prepaid insurance and not-for-profit health maintenance organizations (HMOs) were established to provide fixed-cost services for the masses. 1 Many of the patient-subscribers (often union members) and many of the health care providers in these plans joined as part of their social commitment to quality care through cooperative efforts.