Whether or not seclusion has a place within the treatment of the mentally disordered is one of the longest running debates in the history of mental health care, and it is likely to continue. Controversial deaths in mental health facilities and their subsequent inquiries will further fuel speculation as to how best to manage challenging behaviour. This chapter provides an overview of the history of seclusion, its value or otherwise, its alternatives and the necessary supporting policies for its use. It also offers a practical framework within which seclusion may be considered in the context of psychiatric intensive care units (PICUs).

De-escalation is a term that is often used by psychiatric professionals yet if they asked for a definition of it, there would be differing responses. This chapter outlines not only a definition but the essential elements within its practice and how de-escalation fits into the spectrum of management of challenging and disturbed behaviour.

Virtually all societies have found the need for containment and control of behaviour by physical means. The first words in any discussion about restraint must include the methods of avoiding the need for its use wherever possible. De-escalation, negotiation, meaningful activity programmes and the development of trusting relationships are the necessary first steps. This chapter focuses on the activity of restraint, assuming that due attention has already been paid to the methods of avoiding the need for its use.

Patients presenting with acute behavioural disturbance pose a significant challenge in terms of management of risk to the patient (particularly when there is potentially life-threatening illness and/or injury) and to others. The consultation-liaison (CL) team offers acute advice and expertise across the general hospital setting and has a key role in policy development in collaboration with medical colleagues to ensure timely and effective intervention for patients presenting with acute behavioural disturbance. This chapter explores aetiological factors contributing to presentations of acute behavioural disturbance and approach to assessment. Behavioural and pharmacological interventions are outlined along with guides for optimising assessment and management of patients with acute behavioural disturbance in the emergency department (ED).

This chapter broadens our understanding around how macro and micro levels of conflict come together in the form of ceasefire agreements. It shows how the 2017 Memorandum on the creation of de-escalation areas in the Syrian Arab Republic, negotiated and agreed to by Russia, Turkey and Iran, not only relates to military dynamics but how this agreement influenced elements normally considered the sole purview of the sovereign state such as diplomacy, security and territorial control.

This chapter examines the trajectory of challenge in Syria’s Kurdish regions, which stands in marked contrast to trajectories of contention seen in other areas of the country, which generally tended toward ethnic violence. The regime’s relatively conciliatory response to protest in Kurdish areas and toleration of ethnic group–level institutions, namely its courting of Kurdish political parties and the reciprocation of one party, combined to direct challenge away from violence and toward Kurdish-specific issues.

In the second chapter the existing insights from the literature are treated. How have others thought about and conceptualised escalation and de-escalation? How do violent interactions between rebels and the state escalate? How can we measure escalation? The chapter sets out the methodology that is used in the book.

Chapter ten concludes the book. The main findings are summarised and discussed and some theoretical premises are formulated that could contribute to a further theoretical debate about (de-)escalation. The book concludes that escalation and de-escalation are far from linear, carefully calculated phenomena but more often highly path dependent, inadvertent, if not accidental and beyond any individual’s control. The chapter also translates these findings into considerations for policy and paints some avenues for further research.

In chapter nine the focus is entirely on de-escalation, which compared to the discussion about escalation, is rather under-theorised presently. The starting point form the Cold War ideas on how conflict is supposed to de-escalate, followed by a treatment of the literature on the restraints of terrorism and insurgency whether self-imposed or not. Two hypotheses related to de-escalation are formulated based on the literature about de-legitimation and norm convergence and about an inability shift to continue the conflict, in the shape of a loss of foreign support and defection. The vignette in this chapter is the Chechen independence movement.

Chapter 3 presents in detail the NVR manual for entrenched-dependence interventions. The opening stage is devoted to building the therapeutic alliance, reframing the problem in ways that allow for new options, discussing parental accommodation, working on the parents' narrative of total responsibility, explaining the need for a support network, and training on how to prevent escalation. This stage concludes with the presentation of a therapy roadmap. The second therapeutic stage includes the formulation and delivery of the announcement, and the constitution of a support group. The third therapeutic stage is the gradual and systematic process of de-accommodation, consisting in a series of gradual exposures to diminishing services, infringement of prohibitions and, if necessary, change of living arrangements. The conclusion stage is usually open-ended, offering parents the option of returning to therapy for a short period if crises arise.

In Chapter 2, we argue why parental NVR is well-suited to treating entrenched dependence. We describe why attempts at individual therapy for the adult-child or traditional parental counseling usually fail. These failures have different forms, such as: (a) the adult-child refuses therapy; (b) the adult-child accepts therapy, but entitled dependence persists; (c) the parents are advised to show unconditional acceptance, but the dependence remains unaffected; or (d) the parents are advised to be tough, but are daunted when they stumble on frightening escalation. We argue that parents are almost invariably the motivated partners, that they deserve to be viewed as clients in their own right, and that involving the adult-child would distract the parents and the therapist from their job. We elaborate some central insights underlying parental NVR, such as: (a) that the parents' narrative of total responsibility actually prevents improvement; and (b) that parental accommodation aggravates and perpetuates the problem. The chapter concludes with a description of treatment goals and of what changes can be realistically expected.