Secondary Targets Are Not So Secondary: Commentary on Michael Marks' Case Study of "Jane"


  • Allison K. Ruork


Michael Marks (2022) describes the case of "Jane," a client presenting with multiple concerns and targets for treatment, who was treated over six months using Dialectical Behavior Therapy (DBT) at the DBT Clinic at Rutgers University (DBT-RU). Treatment of Jane was consistent with the principles of DBT and represented significant progress in treatment broadly and, more specifically, clear gains in addressing therapy interfering behaviors, increasing willingness to engage in accurate expression and needs assertion in her romantic relationships, and decreasing hopelessness, which subsequently decreased suicidal ideation.  Despite this significant progress Marks reports ongoing struggles with noticing change as it was happening, polarization, and painful and frustrating interpersonal transactions. In this commentary, I propose that many of the transactional (and highly understandable) pitfalls experienced by Marks and Jane may have been addressed by a case conceptualization that more actively integrated the “secondary targets” in DBT, which are anchored in the dialectical dilemmas represented by three continua: Emotion Vulnerability versus Self-Invalidation; Unrelenting Crises versus Inhibited Grieving; and Active-Passivity versus Apparent Competence. Specifically, I suggest that consistent and thorough inclusion of secondary targets in treatment can decrease the potential for polarization and transactions that lead to stagnation and can make therapy more efficient. In addition, I address some of the challenges to such a conceptualization.




How to Cite

Ruork, A. K. . (2022). Secondary Targets Are Not So Secondary: Commentary on Michael Marks’ Case Study of "Jane". Pragmatic Case Studies in Psychotherapy, 18(1), 102–111. Retrieved from