I have a quandry about "When is it time to end therapy?" for certain clients. There are many factors, however, and they seem complicated.

Factors include:

1. the medical insurance company is deciding therapy has gone on long enough (coming up on 2.5 years) and likely won't pay anymore.

- the therapist (a.k.a. "the guide") and patient (a.k.a. "the traveler") have discussed a few options about how therapy may continue, if and when the insurance decides to stop paying. but nothing has been formalized.

2. the patient has exhibited increased anxiety and fear and has become increasingly closed off in session.

- the patient is exhibiting "fear" and anxiety about:

(a). Being "jarred away" from therapy: being "jarred away" from a caregiver would create a trauma that would mirror and harshly reinforce past issues of mistrust and abandonment. Thus, the patient seems to be bracing for what feels like to this patient like a "foregone conclusion" that something -- even if not caused intentionally by the therapist -- something will come in to tear the client away.

(b) the client is also going into "deeper" areas in therapy and attempting to "draw" out more "fragile" aspects of self (visualized as a 2-year-old). Thus, because the client is approaching this "most fragile" part, the client seems to be pulling inward and changing direction to avoid putting this part in danger.

- Because mistrust has been part of this client's "survival kit" for over 30 years, the client is tapping into this mistrust and feels that the effort the therapist (and an associated bodywork/massage therapist) is putting forth to connect with that "most fragile" part is only being done so that they can "hurt" that "most fragile and delicate" part of self.

3. The client has recently allowed self to be more open to receive care from the therapist, however, this has alarmed the client for fear of becoming dependent on the therapist and the client is retracting onto self and pulling away.

4. The client is beginning to cancel appointments and cut back on appointment that were previously scheduled.

5. The client is aware and has expressed that things are being held back and seems to pride in it.

6. The client used to feel relatively safe calling the therapist between sessions if there was overwhelming emotional pain. However, now the client takes pride and praises self for not calling for help, and continues to stretch out this praise as the weeks pass. The client even destroyed all phone numbers and removed the therapist's number from personal cell phone directories to "resist the temptation to call." And suggests that calling is a "sin".

7. Overall, the client is attempting to get away, before something comes along to pull them away in a traumatic way.

8. The client has expressed concern that perhaps therapy has stopped being about healing self, but just remaining with "someone to take care of me". That issue is something to differentiate though, when is someone taking care of you in therapy separated from healing self?

If the client's fear and anxiety is so overwhelming and the client indicates such efforts to leave (mainly because of this fear), is it wise to allow them to leave or is there something that can be done to safely dissuade them from leaving when it doesn't feel safe.

Recently, the client asked a hypothetical question: "If the fantasy world is safer and more predictable than the real world and the same emotions can be realized in the fantasy world (the only difference, the client says, is that emotions in the real world may be attached to something "tangible" while those in the fantasy may not be - but they are emotions nonetheless and can be sustaining emotions)...why would I want to want to be in the "real world" when it is less safe and unpredictable".

I do not wish to give up on this client, however, the client seems determined to draw away.

Any comments or suggestions or resources to look to would be appreciated.