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Similar to other therapeutic methods, the issue of patient dropout from psychoanalytic psychotherapy presents significant challenges for patients, therapists, and the overall mental health system. While quantitative studies in solution-focused therapies have often explored this issue, a more in-depth understanding can be gained by approaching it qualitatively within the framework of long-term, open-ended psychoanalytic psychotherapy. Eleven patients and four therapists with direct experience of dropout participated in twenty-six in-depth interviews, guided by Corbin and Strauss’s grounded theory methodology. The analysis identified the central theme of dropout as a ‘departure from the imbalanced binary system’, which includes contextual, action-interaction, and consequence categories. The conceptual model underscores key factors contributing to dropout, encompassing both cross-theoretical elements such as the therapeutic alliance and coping strategies, and more specific factors like perceptions of psychoanalytic therapy’s legitimacy in a specific culture and patients’ beliefs about its effectiveness as a therapeutic approach. These findings provide valuable insights into the complex nature of treatment dropout, offering important clinical and scientific implications.