Cultural Considerations

When we talk about mental health—especially experiences like psychosis—it is essential to recognize that there is no single, universal way these experiences are understood or expressed. Across different cultures and communities, there are many valid ways of making meaning of voice-hearing, visions, or altered states. Honoring this diversity means embracing a broader understanding of reality—one that includes different belief systems, values, and ways of knowing. Rather than pathologizing what may be celebrated, spiritual, or deeply personal in some communities, we can hold space for multiple truths and create more inclusive, respectful, and empowering care.

Below are some elements to consider for cultivating an open, respectful, and culturally responsive approach when working with individuals whose experiences, worldviews, and understandings of psychosis may differ from our own:

Spiritual Experience or Psychosis?

Cultural Beliefs Can Be Misinterpreted as Symptoms

What may be labeled as "psychosis" in Western psychiatry can actually be a spiritually meaningful experience in many cultural and Indigenous traditions.

Fear of Misunderstanding Is Real

Individuals from Indigenous or non-Western backgrounds may hesitate to share their spiritual experiences in clinical settings due to fear of being misunderstood or pathologized.

For Māori Communities

In Māori culture (New Zealand), experiences that might be seen as delusional in Western psychiatry may instead be understood as:
- A disconnection between spirit and body
- Trauma opens a doorway to spiritual distress
- A spiritual gift inherited from ancestors (Taitimu et al., 2018)

For Hmong Communities in the U.S.

Hmong cultural beliefs often attribute psychosis to spiritual entities or possession by demons. Healing typically involves traditional rituals led by spiritual healers (Helsel, 2019).

For Aboriginal and Torres Strait Islander Peoples

In parts of Australia, some Aboriginal and Torres Strait Islander individuals may interpret altered experiences as spiritual communication, not symptoms to be treated or suppressed (Hunter et al., 2012).

Clinicians Must Practice Cultural Humility

To provide effective, respectful care, it’s essential for providers to listen without judgment, ask open-ended questions, and explore the cultural context behind a client’s experiences.

Spiritual Understanding Supports Healing

When clinicians take the time to understand spiritual and cultural frameworks, clients often feel safer, seen, and empowered in their healing journey.

Varying Themes Across Cultures: What Voices Mean Around the World

Voices Reflect Cultural Worldviews

The content of voice-hearing is often shaped by a person’s cultural background, including local folklore, religion, politics, and everyday life experiences (Luhrmann et al., 2015).

Themes Differ by Region and Identity

In a comparative study across the U.S., Ghana, India, and China:
- In Shanghai, voices often reflected religious or political concerns, with men more likely to hear political voices and women more likely to hear religious ones.
- Voices were also more relational and recognizable—participants often knew who the voices were.

Maasai Women in Tanzania Show Non-Pathological Voice Hearing

Nearly 40% of Maasai women in a non-clinical sample reported hearing voices. Importantly, they did not see these experiences as signs of mental illness.

Spiritual Interpretations Are Common

Many Maasai women believed the voices were caused by thinking too much or being affected by spiritual forces (described as “too many demons”), and turned to prayer and church as healing strategies (Jarvis, 2025).

Not All Voice-Hearing Is Distressing

In many cultures, voice-hearing is normalized, spiritually meaningful, or viewed as a natural part of human experience—rather than inherently pathological.

What Clinicians Can Take Away

Understanding a client’s cultural lens helps avoid mislabeling meaningful experiences as illness, and opens the door to more respectful, collaborative, and effective care.

Spirituality, Religion & Psychosis

Spirituality Is a Deep Source of Meaning

For many people, religious and spiritual beliefs are core to how they make sense of the world—including their experiences with mental distress.

Spirituality Can Be a Risk or a Resource

Depending on the context, religious beliefs can either protect mental well-being or contribute to distress and symptom severity in people living with psychosis.

Religious Delusions Are Not Uncommon

Between 15% and 39% of individuals diagnosed with psychotic disorders may experience religious-themed delusions, often tied to cultural or personal meanings.

Cultural Context Matters

One key to distinguishing religious delusions from culturally appropriate spiritual beliefs is understanding whether the belief is commonly shared or grounded in the person’s cultural background.

Spirituality Can Support Recovery

Religious or spiritual beliefs may enhance hope, self-worth, and a sense of meaning, which can help buffer emotional distress and reduce negative responses to symptoms.

Faith Can Reduce Aggression & Isolation

Many religions offer social guidance, promote ethical behavior, and provide a sense of community, all of which can support interpersonal functioning and healing.

Religion Can Be Protective Against Suicide

About 1 in 4 individuals report that religious beliefs helped them find meaning in life or discouraged suicide through spiritual coping, connection, or moral conviction.

But It’s Not Always Protective

For some, religion can become a source of despair, especially if healing doesn’t occur or if the person feels rejected by their faith community. In some cases, religious delusions can directly contribute to suicidality.

Gender Diversity, Psychosis & Mental Health

High Suicide Risk

Transgender and gender-nonconforming individuals are 22 times more likely to attempt suicide than their cisgender peers—highlighting the urgent need for affirming, accessible mental health care.

Non-Binary Voices Are Largely Missing from Research

Gender-diverse individuals—especially non-binary people—remain underrepresented in clinical studies, especially those exploring psychosis. This gap leads to care that often overlooks this community's unique needs.

Psychosis Diagnoses Are Disproportionately Assigned

Transgender individuals are diagnosed with schizophrenia spectrum disorders at rates up to nearly 50 times higher than cisgender individuals (Barr et al., 2021), suggesting a strong possibility of diagnostic bias.

Gender Identity Can Be Misunderstood as a Symptom

In some clinical settings, a person’s transgender identity may be mistaken for a delusion or symptom of psychosis, rather than being recognized as a valid and affirming aspect of who they are.

Misclassification Harms Access to Care

When identity is pathologized, it creates an unsafe and invalidating clinical environment—especially when individuals are seeking gender-affirming care.

We Must Do Better

To provide ethical, effective mental health care, clinicians need to remain aware of bias, stay educated on gender diversity, and commit to approaches that center identity, dignity, and lived experience.

Diagnostic Bias & Racial Disparities in Psychosis Diagnosis

Cultural Misunderstandings Can Lead to Misdiagnosis

Western clinical frameworks often misinterpret culturally normative behaviors or expressions of distress—particularly in non-White populations—as signs of psychosis.

African Americans Are Overdiagnosed with Schizophrenia

Research shows that African Americans are over three times more likely to be diagnosed with schizophrenia than their White counterparts—despite similar symptom profiles.

Clinician Bias Plays a Role

Studies suggest that clinicians may “overvalue” or exaggerate the severity of psychotic symptoms in Black patients, often rooted in racialized assumptions about behavior being "bizarre," "aggressive," or "dangerous."

This Pattern Is Not Limited to the U.S.

Similar overdiagnosis has been observed among Afro-Caribbean individuals in the UK, even though rates of psychosis in Jamaica are average, highlighting a systemic, global issue of cultural misinterpretation in psychiatric diagnosis.

Historical & Political Context Matters

In the 1960s, some Black Americans protesting racial injustice were labeled as schizophrenic—a politicized misuse of diagnosis aimed at silencing dissent. Traits such as a “confrontational demeanor” were pathologized rather than understood as responses to oppression.

The Stigma of Schizophrenia Amplifies Harm

Schizophrenia is one of the most stigmatized psychiatric diagnoses. When combined with racial bias, it can reinforce stereotypes and lead to mistrust, miscommunication, and long-term harm in therapeutic relationships.

Cultural Competence Isn’t Enough—We Need Cultural Humility

Clinicians must go beyond surface-level awareness to question their assumptions, remain curious, and seek to understand the cultural context and lived experience behind each person’s story.

Sources:

Barr, S. M., Roberts, D., & Thakkar, K. N. (2021). Psychosis in transgender and gender non-conforming individuals: A review of the literature and a call for more research. Psychiatry Research, 306, 114272. https://doi.org/10.1016/j.psychres.2021.114272

Escobar, J. I. (2012). Diagnostic Bias: Racial and Cultural Issues. Psychiatric Services, 63(9), 847–847. https://doi.org/10.1176/appi.ps.20120p847

Jarvis, G. E. (2025). Cultural variations in psychosis: Recent research and clinical implications. Transcultural Psychiatry. https://doi.org/10.1177/13634615251324088

Jarvis, G. E., Iyer, S. N., Andermann, L., & Fung, K. P. (2020). Culture and psychosis in clinical practice. A Clinical Introduction to Psychosis, 85–112. https://doi.org/10.1016/b978-0-12-815012-2.00004-3

Helsel, P. B. (2019). Paper spirits and flower sacrifices: Hmong shamans in the 21st century. Journal of Religion and Health, 58(3), 1006–1016.

Huguelet, P. (2020). Spirituality, religion, and psychotic disorders. Handbook of Spirituality, Religion, and Mental Health, 79–97. https://doi.org/10.1016/b978-0-12-816766-3.00005-7

Hunter, E. M., Gynther, B. D., Anderson, C. J., Onnis, L. L., Nelson, J. R., Hall, W., Baune, B. T., & Groves, A. R. (2012). Psychosis in Indigenous populations of Cape York and the Torres Strait. Medical Journal of Australia, 196(2), 133–135.

Taitimu, M., Read, J., & McIntosh, T. (2018). Ngā Whakāwhitinga (standing at the crossroads): How Māori understand what Western Psychiatry calls “schizophrenia.” Transcultural Psychiatry, 55(2), 153–177. https://doi.org/10.1177/1363461518757800