Impairments in metacognitive capacity are a core barrier to recovery for many with borderline personality disorder. Metacognition refers to the processes which enable individuals to access, understand, and integrate their ideas about the mental states of themselves and others, and then use that information to recognize and respond adaptively to psychological challenges. Borderline personality disorder is believed to be amenable to psychotherapy, but few of the established treatment protocols specifically target metacognitive capacity. This case illustration provides a descriptive account of an individual with borderline personality disorder in a long term institutional setting who participated in 14 months of a novel psychotherapy that specifically targeted metacognitive processes: Metacognitive Reflection and Insight Therapy. The vital elements of the intervention are elaborated with examples from the case illustration. Case conceptualization, outcomes, and potential prognosis are also presented and discussed.