In 2020, 82 million people worldwide were forcibly displaced. In the same year, the UK received asylum applications for over 37,500 people. 76% of initial decisions made in the year to June 2022 have been grants of protection, meaning they have been awarded refugee status or humanitarian protection. However, many people wait years for a final decision on their claim. COVID-19 has exacerbated this issue and extended the backlog further. Most refugees are survivors – of transit, war, torture, trauma, loss. Recognition of the mental health needs of these survivors in countries of settlement is growing and with it an acknowledgment of the complexities faced. Despite finding relative security in their country of asylum, settlers are often faced with new psychosocial stressors as they simultaneously contend with the impact of their trauma in a foreign settings with cultural and language differences. Providing access to good quality mental health care, one that caters to these complexities, is essential.

We report the case of a 25-year-old, single, Tigrinya speaking, male Eritrean asylum seeker. In August 2022 he arrived into the UK in the back of a lorry having left Eritrea on foot three years previously having fled conscription. Whilst migrating, he was tortured, witnessed killings, was human trafficked and enslaved. Shortly after arrival in the UK he developed a psychotic illness and was admitted to an acute psychiatric ward. Treatment resistant schizophrenia emerged, clozapine was commenced and his condition improved.

The journey to clozapine was not smooth. His clinical presentation was complex, in the beginning we struggled to establish the source of his distress unsure of what was psychosis and what were symptoms of post-traumatic stress. We struggled to distinguish medication side effects from somatising. We struggled communicating, building trust, breaking down language and cultural barriers.

In order to treat the illness we had to understand it and our patient. We adopted a multidisciplinary approach to deliver, in the first instance, principals of psychological first aid: addressing the refugee agenda as part of meeting his basic needs. With time and thanks to a wonderful interpreter we were able to build trust, strong and safe lines of communication. Slowly we became better interpreters ourselves, more able to decipher his distress. The interpreter helped us to be more culturally competent, thus, building our connection stronger. As the young man's acute condition settled, he began to trust us and his psychosis abated.

Our case highlights the importance of holistic care when managing displaced individuals in psychiatric settings. Interpreters are invaluable to trauma informed practice, beyond facilitating verbal communication they can help us to understand the culture of the people we are supporting, helping us to provide connection beyond the words. Trust in the context of psychosis and trauma in a displaced individual is hard earned but should be prioritised.