I've written before about how jouissance, getting off, the libidinization of anxiety, etc. often shows up in a variety of ways in patients.
I've been trying to figure out ways to work with it and have found one that is relatively simple that ends with the getting off ultimately pointing to passive aggression.
1. You have a patient who describes reckless behavior.
2. You talk about what they think can happen as a consequence of this behavior.
3. You as the patient if it feels true or not when the say "I don't care if I live or die"
4. They say it and say it feels partly true. If you aren't practiced at using this method, you sometimes have to remind them that this is only for a part of themselves and everyone has different parts that feel in different ways.
5. You ask them to talk from the place (the part of them) for which it feels true.
6. If this doesn't go somewhere, or after it does, you ask them what their family or "loved ones" would feel if they died.
7. It's usually good to ask about the mother for borderline patients and the father for neurotics, if it doesn't go anywhere.
8. When they talk about how someone would be devastated or sad, then ask if he or she might also feel responsible, feel guilt, or feel like he or she failed the patient.
9. Then ask the patient if it feels true to say "You failed me mom" or whatever word the patient might have used to get this across.
10. This will usually be accompanied by some anger and bringing up stories about how the parent or person failed them.
This will usually provide some relief but has to be followed up with discussion about the relationship with the person. Does the patient want to have a closer relationship with them (if they are alive)? Often there are feelings that the parent (if this is the person in question) doesn't let the patient know what is going on with him or her and the patient stubbornly keeps his thoughts private.
The patient often doesn't feel like the parent wants to take him or her seriously (as an adult).
The patient is scared to ask the parent to do so because that could end up with a rejection or dismissal.
To try to set up a straight forward goal to talk to the parents will often not end well because it's too frighting for him or her.
One approach here is for the patient to tell the parent something along the lines of "I feel like there's things you never tell me about (such as x) and I know that I don't tell you a lot about what's going on with me. If you'd like me to tell you what's been making me unhappy and what's been going on with you then let me know".