How Metacognitive Therapy helps with personality disorders and complex diagnoses
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Learn three powerful metacognitive therapy steps to stop the worry cycle, reduce anxiety, and feel calmer in everyday life.
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Complex diagnoses or personality disorders, such as Borderline Personality Disorder, Complex PTSD, Body Dysmorphic Disorder, and Substance Abuse Disorder, are generally considered difficult to treat or unlikely to change.
These patterns tend to be long-standing, showing up early in life and across many areas, from work to friendships, romantic relationships, and family dynamics. And unlike anxiety or depression, which can come and go in episodes, these conditions often come with enduring coping strategies.
Many people with complex diagnoses have spent years in therapy, deeply analyzing their past, their personality, and their relationships. But despite all this work, they often feel stuck in the same loops. Metacognitive Therapy offers a fundamentally different approach to understanding why these patterns persist, and how change is still possible.
A different way of understanding “symptoms”
Traditional therapies often conceptualize behaviours like self-harm, substance use, risky behaviour, or paranoid thinking as symptoms… things that happen to a person and reflect an underlying disorder. But in Metacognitive Therapy, these behaviours are viewed as strategies.
This distinction matters, because symptoms are seen as out of your control. Strategies, on the other hand, are behaviours and mental processes that someone (understandably) will actively do in an attempt to cope. And anything that’s a strategy can be worked with and changed.
The role of repetitive thinking and threat monitoring
From an MCT perspective, many complex and personality-based conditions are maintained by habitual patterns of worry, rumination, threat monitoring, and unhelpful behaviours, which only intensify under stress.
Across diagnoses, a common thread appears: repetitive thinking aimed at preventing danger or emotional pain. This could look like hours or days of worrying before a conflict, and then replaying conversations to analyze what went wrong. In relationships, it can show up as constant scanning for signs of rejection, betrayal, or abandonment. Or it can crop up in harsh self-criticism and shame-based narratives like “I’m broken” or “There’s something wrong with me.”
When difficult emotions rise, many try to manage those feelings through controlling behaviours, self-harm, avoidance, substance use, or impulsive actions. And while these strategies may bring temporary relief, they ultimately create more problems.
Download our best tips on reducing anxiety and worrying
Learn three powerful metacognitive therapy steps to stop the worry cycle, reduce anxiety, and feel calmer in everyday life.
Your beliefs can keep the loop going
What maintains these patterns isn’t the thoughts themselves, but the beliefs you hold about yourself and your thinking. Many people with complex diagnoses hold strong beliefs about their mind, such as:
- If I stay vigilant, I’ll stay safe.
- Analyzing everything protects me from pain.
- If I stop monitoring, something bad will happen.
- Once my thoughts start, I can’t stop them.
- My mind is broken — I can’t change.
These beliefs make worry, rumination, and threat scanning feel necessary, even when they’re causing distress. Over time, people stop believing change is possible at all.
How MCT works with personality disorders
Rather than focusing on specific thoughts or diving into past traumas, Metacognitive Therapy zooms out and targets the processes (worry, rumination, threat-monitoring) maintaining distress.
MCT works by helping people to:
- Challenge beliefs that thinking must be controlled or monitored
- Recognize which responses are coping strategies, VS experiences outside their control
- Learn that you can direct your attention and behaviour even when you feel strong emotions
- Reduce time spent engaging with unhelpful thinking and coping patterns
When working with complex, treatment-resisitant, or long standing personality-level patterns, treatment is typically longer than the short-term MCT treatments used for anxiety or depression. Reducing entrenched coping and thinking styles and deeply held beliefs about oneself takes time (often up to a year or more) and sometimes involves collaboration with psychiatrists and even partners or family members.
While MCT is usually position as a short-term intervention, it shouldn’t be overlooked for complex diagnoses. In conditions like these, the approach is adapted thoughtfully and applied over a longer course, with promising clinical results emerging, and many successful recovery cases in our clinics.
When you’ve tried everything else…
This approach can feel completely the opposite to therapies you might have tried before, which might be an adjustment. Instead of asking why you are the way you are, MCT asks what’s keeping the problem going now. It doesn’t require reliving the past endlessly or fixing every thought you have about yourself. Instead, it focuses on freeing people from the patterns of thinking and monitoring that fuels their distress.
For people who have spent years in therapy but still feel stuck in repetitive mental loops, this method offers another way forward. Through working with an MCT-certified therapist, you can expect to achieve more emotional stability with reduced impulsivity and self-harming behaviours, improved distress tolerance and more cognitive flexibility, and the ability to maintain stable relationships.
When dealing with complex diagnoses, sometimes, we simply need to use a different lens… one that shifts the focus to understanding how you have learned to cope, and how you can move forward without the trap of coping strategies.
