Schizophrenia affects approximately 24 million people worldwide. But does schizophrenia present the same way in every country? How do culture, religion, tradition, or even politics influence the presentation of schizophrenia?

Cross-cultural awareness of psychiatric symptoms helps us to understand our ever-changing global society. In today’s episode, hosts Rachel Star Withers and Gabe Howard explore studies and cases across the world and throughout history to discover how culture influences schizophrenia and its treatment.

Joining is guest Nidhi Sinha, a final year PhD student in psychology who has been researching thematic analysis of individual experiences of audio hallucinations in India.

Nidhi Sinha

Nidhi Sinha is a final year PhD student in cognitive psychology at the Indian Institute of Technology Hyderabad (IITH), where she is exploring the affective, cognitive, and cultural cues of subclinical depression. She is also a visiting researcher at the Cognitive Science lab, International Institute of Information Technology Hyderabad, India. As a former CBT psychologist, Nidhi has worked with people with mental health conditions, providing therapy and support. Her current research focuses on improving the psychometric properties of existing diagnostic systems while exploring the subjective experiences of people with mental health conditions, such as psychosis and depression. Nidhi believes that understanding the social, political, and cultural factors of mental illness is crucial in developing effective diagnostic and intervention methods. She advocates introducing indigenous and traditional healing practices, such as meditation and yoga, to name a few. Her work on mental disorders (qualitative and quantitative) has been published and presented in top national and international journals and conferences.

Rachel Star Withers

Rachel Star Withers creates videos documenting her schizophrenia, ways to manage and let others like her know they are not alone and can still live an amazing life. She has written Lil Broken Star: Understanding Schizophrenia for Kids and a tool for schizophrenics, To See in the Dark: Hallucination and Delusion Journal. Fun Fact: She has wrestled alligators.

To learn more about Rachel, please visit her website, RachelStarLive.comm.

Gabe Howard

Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.

Gabe makes his home in the suburbs of Columbus, Ohio. He lives with his supportive wife, Kendall, and a Miniature Schnauzer dog that he never wanted, but now can’t imagine life without. To learn more about Gabe, please visit his website,

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Schizophrenia. Hosted by Rachel Star Withers, an advocate who lives openly with Schizophrenia. We’re talking to experts about all aspects of life with this condition. Welcome to the show!

Rachel Star Withers: Welcome to Inside Schizophrenia, a Healthline Media podcast. I’m your host, Rachel Star Withers, here with my excellent co-host, Gabe Howard. Schizophrenia is a serious mental disorder in which people interpret reality abnormally. This may result in symptoms of hallucinations, delusions and disordered thinking and behavior. According to the World Health Organization, schizophrenia affects approximately 24 million people worldwide.

Gabe Howard: Which is 1 in 300, Rachel.

Rachel Star Withers: How does schizophrenia differ across the world? What influence does culture, religion, tradition or even politics have on schizophrenia? Joining us today is Nadia Sinha, a final year PhD student in psychology who has been researching thematic analysis of individuals’ experiences of audio hallucination and hearing voices in India.

Gabe Howard: This is a fascinating subject for me, Rachel, of course, because you hear about people saying, well, I saw Elvis. Well, clearly a hundred years ago, nobody could say I saw Elvis. Another popular one that we hear is that the TV is talking directly to me. Well, obviously, if you don’t own a TV, you’re or you lived in a time that didn’t have TV, that’s not going to be a delusion or a hallucination that you can experience. And now, of course, we have media, we have movies and films that have heavily influenced the way that people who have never experienced hallucinations and delusions understand them or feel about them. A real, real popular one in America, it’s a movie that came out in the 70’s, so I’m shocked that we’re still using it as an example, is One Flew Over the Cuckoo’s Nest. Rachel, you’ve experienced hallucinations and delusions. Is it like One Flew Over the Cuckoo’s Nest?

Rachel Star Withers: No, it’s nothing like that movie. And I think that’s for whatever reason, that’s like one of the main standards of our culture is One Flew Over the Cuckoo’s Nest with crazy people, with mental hospitals, with electroconvulsive therapy. Like that’s what you picture. This one movie is just like ingrained in so many people’s minds. That’s their go-to. That’s what they expect to see.

Gabe Howard: And of course, it’s not reality, as we’ve talked about on this show before. Popular culture is not a good place to get medical information. And I also want to add, that movie is really old. It’s a great movie if you really like movies, but it doesn’t teach you anything about the treatment of schizophrenia in 2023. And it really didn’t teach us much about the treatment of schizophrenia when it came out.

Rachel Star Withers: Oh, I think it was detrimental. It doesn’t show mental health in a good perspective and it doesn’t show people with mental health disorders in a correct light. They’re seen as just these fun guys who like to have fun and just no one’s letting them, like, go out there and have a good time.

Gabe Howard: They just want to go on a boat.

Rachel Star Withers: Yeah,

Gabe Howard: They want to experience life.

Rachel Star Withers: Yeah.

Gabe Howard: They want to date women. And they say it in the most misogynistic way as well.

Rachel Star Withers: Yeah.

Gabe Howard: But I do want to ask you a question. As someone who lives with schizophrenia, Rachel, is there a movie or a pop culture representation that you think does portray schizophrenia in a more realistic light?

Rachel Star Withers: Yes, there’s lots of little ones. I always hate to give like one like that, this is the perfect movie / TV show example. There is not one. And even if I found one, someone else with schizophrenia might watch that and be like, that is nothing like what I go through. One thing I love is that if you have Netflix, Hulu, all these different streaming services, you’re getting shows now from around the world and some of them present different mental health disorders differently and they show different things going on in the hospitals that I’m like, oh, I’ve never seen that before. And whether it’s like little things or big things, it’s opened us up to a much larger culture. If anyone out there watch Squid Game was a huge show on Netflix, made in Korea, and it just blew up and everyone was talking about that all over the world. Where we’re going is much more globalized. The culture is going to affect the whole world a lot easier. And that’s a good and bad thing because depending what that content is.

Gabe Howard: One of the things that it sounds like you’re saying is that hallucinations and delusions are not a one size fits all, that every person who experiences them are not going to experience them in the same way. And that culture can really influence how you experience these issues.

Rachel Star Withers: It can also experience how we express something that is happening to us. When I was little, I would do something that was called watching TV in my mind because I was a little kid and that’s just what I called it. That was what I thought was happening. And that’s how I would describe it. What was really happening was I was dissociating and going inside of my head. It was not healthy. It was weird. As a kid, I didn’t know that. I just knew I could go inside my head. What’s interesting in South Asia, many people with psychosis who do the exact same thing relate it to religion. They relate it to meditation, to finding an inner detachment. What they’re describing, though, many times is part of their psychosis, but they don’t know how else to describe what’s happening. It’s that I’ve fallen into a meditative state because that’s what the culture talks about around them.

Gabe Howard: It really seems like when people talk about these symptoms, it’s all in your head. Are there any physical symptoms of hallucinations and delusions?

Rachel Star Withers: What most people are going to say is, well, yeah, if the person starts acting crazy or they start talking to no one, that’s what we assume, right? That is a sign somebody is losing touch with reality. Very incredible, there is a Japanese mental hospital who observed something and there were different patients who had schizophrenia specifically who were doing very odd posturing. And it was something that is Japanese traditional Japanese settings. It is not something you would see in a hospital and it is not something you would do towards clinicians. What I mean by posturing is one of them is you drop down to the floor with your face on the floor you don’t move, like you’re begging for forgiveness. A lot of times we’ve seen this in mafia movies. You know, the guy drops down like, please don’t kill me. It’s similar to that, but it’s an old traditional type of Japanese movement. The thing they start asking these patients, why were they doing it randomly? And what they found out was that it was in response to their hallucinations.

Rachel Star Withers: And the worse the patient got, the more formal they got in their posturing. When they got antipsychotics, they stopped doing those weird postures of dropping to the floor. Their idea behind what was happening was that as the Japanese person lost touch with reality, they started to express themselves more formally, and that was showing that their social cognition was going. They didn’t know what was the appropriate way to act around people around them. And it’s funny because the minute I read that whenever my brain starts to get off, I get incredibly apologetic because it’s like my brain I’m trying to think and I keep saying, I’m sorry, excuse, you know? And I just immediately thought that that’s what’s happening. But if you don’t know that and you have a person with schizophrenia who keeps dropping to the ground, when you come by, you’re going to think it’s catatonia. You’re going to think there’s some other situation going on there when in reality, no, this is in that person’s mind the correct way to respond.

Gabe Howard: As you were talking, I was thinking about saying hello by bowing. And we see this in movies all the time. Now, if I walked into a room and I bowed at everybody, they’d think, well, that was really weird. Why is Gabe bowing? Now, if I was a member of a culture that bowed Hello, if I walked into a room and didn’t bow, they would think, well, that’s really weird what’s going on there? Is he being rude? Is he having a mental health system? Etc. So the identical behavior or non-behavior can mean something entirely different in two separate cultures. In America, excessive apologizing is like, okay, that’s weird. Why is she apologizing so much? Whereas in other cultures, excessive bowing could be a problem and it might not also be seen immediately. Again, just like with the apologies, it’s like, oh, well, maybe she’s really, really sorry and I just need to reassure her it’s okay. It’s not a sign of any mental illness. Whereas in another culture, excessive bowing might be seen as, okay, they’re nervous or they’re worried it might not directly link back to schizophrenia, even though they’re the same actions or again, non-actions, someone observing them could come to a very different conclusion about why the person is behaving that way and not tie it back to schizophrenia symptoms at all.

Rachel Star Withers: It’s important when you have a person who is dealing with psychosis or is dealing with different things or behaving abnormally, it helps to ask them why. To ask them what is the meaning of you doing this? Don’t just assume that, oh, okay. Such and such. This person dropped to the ground because they’re having, you know, a psychotic episode. Poor them. No, you don’t really know. Ask, why did you do this? Okay, well, it could have been in prayer. I did it because I was scared. I did it because. Or as an apology to you and you’re like, well, what are you apologizing for? Ask patients, ask your loved ones who have, why are they doing this specific thing? Because whatever it is, it makes sense to them. Somewhere there’s a reason. This is what happens with me. I get these horrible headaches. I call them nail headaches because it feels like there’s a nail in my head. So, what do you use to get a nail out? A hammer. And now you have Rachel in the garage looking for a hammer to take to her head. And if you’re like. Rachel, what are you doing? That’s crazy talk. You can’t fix your headache with a hammer. But I take out nails with a hammer. Obviously, it makes perfect sense to me. So, ask because it can kind of help you understand more. What is that person going through?

Gabe Howard: I think it’s very important to acknowledge your point that the world is getting smaller. So, we have people from other cultures living in America right now. So, we might not understand that the reason that they’re doing something is because of schizophrenia. We might think, oh, that must be part of their culture that we are unaware of. And then we would miss that symptom entirely. Just assuming that there was a language barrier or a cultural barrier or a cultural misunderstanding. And while it’s abnormal to us, it’s perfectly normal to them.

Rachel Star Withers: Cultural changes around us can actually mirror our symptoms. One very interesting thing, and it’s hard with these studies because it’s kind of just a little mixture of what one doctor somewhere wrote down. Okay. Because obviously, we haven’t ran a study from the 1900s straight through. But around the 1930’s, during the Great Depression era, people with psychosis, many of their hallucinations and delusions revolved around wealth and having special powers. So, it’s kind of like the opposite of what was going on in reality. And they think maybe they were their brain would go that way to help them deal with reality, where they had nothing, where they were starving would be the hallucination was that it was the opposite. Then around 1945 to the 50’s, after World War II, many of the delusions and hallucinations reported had to do with heaven, had to do with hell. The afterlife. And you think that, yeah, the world has just come out of this huge thing. They’re dealing with all of this and people’s views were very bleak. And as the Cold War ended into the 80’s, they found that patients reflected a different type of negativity. It was more like visions of blood, snakes, dead animals. And when you kind of think back to the 80’s, that kind of cool, edgy era stuff, like, yeah, you have like the punks that were like wild looking. They had like, the glam looks. Yeah, I could kind of see blood, snakes kind of fitting in there. Just kind of like wild stuff. Like, okay, yeah, it makes more sense there.

Gabe Howard: I think another good example over time is how language evolves. Right? Back in our generation, if we said we were bad, Michael Jackson convinced us all that bad meant that you were awesome and cool and good. And today’s generation says, well, that was sick and they don’t mean ill. They mean that was something that was awesome. And you know, speaking of ill, the Beastie Boys Licensed to Ill.

Rachel Star Withers: Yeah.

Gabe Howard: It meant that you were super cool. The point is, is that language is constantly evolving. So, if you started to yell something like, I’m bad, I’m bad, I’m bad, in 1990, you could be saying I’m really super cool. But if you started yelling, I’m bad, I’m bad, I’m bad, in 19 30, you could be expressing deep inner turmoil or pain or pessimism. And the way that society responded to you would be very different. It took me a while to figure out that sick meant coo. So, if my six-year-old niece came up to me and said, Uncle Gabe, I’m sick, I’d be like, what’s wrong, honey? What can I do. And I would have misread what she was saying. She was actually telling me that she did great at her video game, but I would misinterpret that. But of course, the stakes are very, very high when you’re misinterpreting these things when it comes to somebody who may or may not be experiencing hallucinations or delusions in schizophrenia. And it’s super easy to do.

Rachel Star Withers: And many of the studies that have been done on all this have been done from a European, American, very white point of view. That is our point of view. So, when we look at delusions, they’ll be like, yes, delusions. Then the content of them has changed over the next 50-100 years. You to think like, wow, it must take a long time then, right? Well, in South Korea, they kind of found the opposite because in the mid 80’s, South Korea was under military dictatorship. 1987, they had a national election and they had a nonmilitary regime come in and between the late 90’s to 2000. So, all of these pretty much boom, boom, boom, boom, boom, they had a free, democratic society. They notice that the paranoid delusions went down in people as the political changes happened and they found the same thing happening in different countries that have regime changes. So, it’s not just a, oh, it takes 50 years for this to get to the schizophrenics’ mind. No, it depends on who you’re asking. So, the culture of what’s going on around people comes out in hallucinations and delusions very quickly, because, again, that’s the life you’re leading and it’s being reflected in what’s going on inside of you.

Gabe Howard: Much in the same way that dances changes. I mean, we’ve had the twist, the Freddie, the Macarena and whatever age you are, you know, high school wise, that’s probably your favorite dance. The Macarena will always have a special place in my heart. The cha-cha slide has managed to stay around forever. But obviously, whatever age you are, you may not have even heard of some of these dances. I intentionally brought up the Freddie because that was a dance that was really popular in my dad’s era.

Rachel Star Withers: I have no idea what that is.

Gabe Howard: You’ve never done the Freddie? Do the Freddie? Yeah. It was a super popular dance. You should absolutely look it up. Schizophrenia is not one size fits all. I honestly don’t believe that anyone listening believes that every single person living with schizophrenia is exactly the same. But what we also have to be careful of is we get support from each other. so, we go out and we talk to somebody whose loved one was diagnosed 20 years ago and they’re telling us their experience from 20 years ago. And then we go to apply that to our loved one today. There’s all kinds of reasons that that could change. Remember, 20 years ago, streaming didn’t even exist, and now it does. The world is constantly evolving. So, we can’t just take that boilerplate from somebody who we met in a support group or read about online because things change so rapidly from generation to generation.

Rachel Star Withers: And even though there’s all this change, there is a core that stays the same. One of the very common delusions with schizophrenia is that you’re being watched, is that you’re being followed. It’s this paranoid delusion. And this is across the world. This is three different examples across the world, Gabe. And you’re going to see the same thread. In 1810, a hospital patient was recorded describing a device called the Air Loom, and he believed it was used by villains to influence his thoughts and trigger the assassination of King George III. A century later, in 1919, a different patient across the world described a schizophrenic influencing machine that used boxes, cranks, levers, batteries, wires and air currents to influence his thoughts. And then coming up, 1992, there were many paranoid delusions reported being involved with satellite dishes. And this happened around the time that whenever the satellite dish became popular in people’s neighborhoods that people saw them and that was now okay, they’re using the satellite dishes to control my thoughts. So, the actual hallucination and delusion is the exact same all the way through. But you see how the culture, what was going on around these people changed, how the symptom was presenting, how it was presenting it to themselves and to others, what they were talking about.

Gabe Howard: It reminds me of the through line of generations. Every generation from my grandparents’ generation, through my generation, to my nieces and nephews’ generation. Well, we all have in common is that we’re worried. We’re worried about social unrest. We’re worried about money. We’re worried that we’re going to be protected and okay. But it shows up in different ways. My grandmother still talks about the Depression. My mom still talks about duck and cover. My generation still talks about, you know, we had a lot of fire drills and we were just super worried that the building was going to catch on fire or a tornado was going to blow it over and things like that. And now we have active shooter drills. The through line is that everyone is worried that society is going to end. It’s just what we’re worried about specifically that changes. So, you can find that, you can find that everybody is essentially saying the same thing, but it presents so dramatically differently year to year culture to culture and even person to person. The reality is, is that it’s a symptom of schizophrenia. And while it presents different, the through line is its debilitating hallucinations, delusions, these things are real symptoms of schizophrenia. They’re just presenting in different ways across time culture, even things like cities and states.

Rachel Star Withers: Including religion. And unfortunately, what’s been seen to happen is that religious delusions tend to be associated with increased severity of psychosis. Once a patient starts raving that they’re Jesus or they’re talking back and forth to God or they’re full of demons, or there’s demons influencing them. They think that yes, this person is more severely ill. But right away I think about the fact that I’m I’ve grown up in a very religious area here in the southern US. So, it’s normal for me to hear people talk like that and not think, oh my gosh, that person is crazy. They’re having a hallucination. Last night in boxing class, a woman was talking about how God touched her and she just felt him go through her. And no one in the class was like, oh my God, this woman is has gone insane. That was like a normal thing to say.

Gabe Howard: The way people talk in their own towns, their own homes, their own cultures, their own families is very normal because we are used to it. But if you’re not used to it, then those expressions, those, as you mentioned with religion, can seem like an affront or a problem and they may well not be. It complicates someone’s ability to evaluate someone and decide if that’s just their personality or if this is a symptom of a very serious disorder.

Rachel Star Withers: When we look at the studies and many of the textbooks of what we know about mental health in general, it’s all seen through a very Western view, a very Western lens. Even the different studies they’ve done about religion over and over, I was reading where it would have the delusions the person was having, and it was like, how many had delusions about God, Jesus, the prophets, the saints, demons, Mary. Right away, that’s a big clue that okay, we’re only doing this study in places with Christianity or Catholicism being the main religion around. That was just like, okay, there was there were no other religions involved in this. So, this had to have been at a place where that was the dominant religion. And it makes you wonder if people with schizophrenia in other religious areas, do they have hallucinations about those religious figures? It’s all very interesting when you look at it. Another thing that’s come up is the fact here in Western culture, European, American, we see things as reality and fantasy. Those are very distinctive, and if you can’t tell the difference, you’re probably falling into schizophrenia. That’s kind of the whole core of schizophrenia is you’re losing touch with reality. Well, one study looked at different areas, including California, Ghana and South India, and they compared the different people with schizophrenia there. What they found were the Americans readily used the diagnostic label of schizophrenia and could even recite the diagnostic criteria, which is hilarious because that’s like me. I have no problem saying, yeah, I’m schizophrenic, I have schizophrenia. That was me to a tee. Whereas different patients in Ghana and India really didn’t use diagnostic labels about themselves. And when they had their hallucinations and whatnot, they weren’t necessarily bad.

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Gabe Howard: And we’re back, discussing how culture influences schizophrenia. Rachel, I think that might actually be a great segue to bring on our guests. Can you tell our audience about her?

Rachel Star Withers: Yes. I got to speak to Nidhi Sinha, a final year PhD student who has been studying the experiences of Indian patients with schizophrenia who have audio hallucinations and the experiences of their caregivers who are with them.

Gabe Howard: Let’s go ahead and roll that interview now.

Rachel Star Withers: Today, we are excited to be speaking with Nidhi Sinha. Thank you so much for joining us today, Ms. Sinha.

Nidhi Sinha: Uh, thank you. Thank you so much, Rachel, for having me.

Rachel Star Withers: First of all, I always like to ask people, what has attracted you to study psychology?

Nidhi Sinha: Uh, for me, like, I’ve always been fascinated by, you know, how people and behavior, our mind influences our behavior. So that was one of the factors that persuaded me to study this discipline. I was also always interested in how cultures shape our the way we behave, the way we look at things. So, whenever I, I had people from different state, friends from different state who would be my friends. And in college, when I used to interact with them, even in India, there’s a lot of cultural diversity. So, within few kilometers I could see a huge difference in how they look at the same thing, the way I would look at differently. It always amazed me that culture is a really big factor in shaping our personality, the shaping our, you know, outlook toward our lifes.

Rachel Star Withers: That’s great. Well, thank you so much. I think it’s wonderful when we get anyone who is excited and passionate about learning about how to help people with mental disorders and just learning about the brain.

Nidhi Sinha: Yeah.

Rachel Star Withers: Now, you’ve done some amazing research recently about the thematic analysis of individuals’ experiences in voice hearing in India. What led you to study that?

Nidhi Sinha: So, when I joined my university, which is IIT Hyderabad, like as a part of the coursework, we have to do one course which is called Critical Psychology, Culture and Mental Health. So, in that lecture I got to know that various disorders, whether it is depression, whether it is schizophrenia. Different cultures would perceive and would understand the symptoms and the illness in general differently. My professor, Dr. Ranganathan, encouraged me to pursue research where she wanted to understand that how people with schizophrenia, especially people who hear auditory verbal hallucination, how do they understand their environment? What are the coping mechanisms they use? Basically, understanding their phenomenology of illness. But when I went into the field and, you know, went into the mental hospital to interview them, that’s when I realized, that these patients are always accompanied by their caregivers. So that motivated me to add on another layer to this research where I tried to understand that how caregiving experiences, also is different in different culture.

Rachel Star Withers: What were some of the ways that individuals with schizophrenia differ in their experiences depending on their cultural settings?

Nidhi Sinha: Yeah, so, when we talk about schizophrenia, right, it is very important to understand that this is a very complex mental disorder and you know, it can manifest differently depending on, you know, what kind of culture, what kind of environment you grow in. So, if you try to understand in the way individuals with schizophrenia differ in their experiences, especially in the context of their cultural setting. One of the ways in which you would see a difference, cultural difference based on symptoms would be the how the illness is expressed in the culture. So, in some cultures you may see that the symptoms of schizophrenia are expressed in a very typical way. Like in Western culture, you would see that people would hear voices that are very scary or sad or threatening, and most of the people would have a very difficult relationship with the voices that they would hear. But if you look in the culture, which is more collectivistic, say, for instance, in Africa or in India, you would see that most of the patients would hear voices which are more fun, less threatening, more less harmless. So also, like if we try to understand what kind of relationship they share with the with their voices, it would be like the family members and they would hear the voices that are often from their of their parents or their grandparents.

Nidhi Sinha: So, in terms of the content, they there would be a cultural difference that you would see in different cultures. Another way, think in which you can see a difference in experiences of symptom would be how, you know, stigma and discrimination is associated with individuals with schizophrenia. Discrimination is stigma is something which is very prevalent in all the culture, be it in West or in the East. But if you see in the Western culture, what you would notice is that there are people, despite the stigma and discrimination, they are having their voices where they are sharing their experiences with others. For example, your own podcast, right? You are having people from different walks of life who are sharing their hallucinatory experiences and they are well received by your audience as well. But in collectivistic culture, what you would notice that the awareness and the acknowledgment of the disorder is still very poor and these experiences are still kind of seen as a weakness or a spiritual weakness, which may lead to a larger social isolation and discrimination against those people. If you look at the level of the support or social support that they receive in the care, we will see the differences, cultural differences, particularly. In some culture, especially collectivistic society, families are very much involved in the care of the individual. So, like I said, when I was doing my research, I found patients are always accompanied by their, you know, family member, be it their brother, their parents, their wife, husband. So, there were always someone who were there to, you know, help them in their journey of recovery.

Nidhi Sinha: But in the West, most of the time, the mental illness or schizophrenia is seen as more of an individual problem. And that the people who are experiencing the disorder should be the one who should be dealing with the voice all by themselves. So, I think in terms of social support, there is also a difference. Even like if we try to see how they are getting treatment for their illness in terms of help-seeking behavior for treatment of the symptoms, especially hallucinatory experience. We will notice that in cultures like India or Africa, traditional healing practices or religious beliefs are more prioritized as compared to what you would see in the Western treatment. In my research, I had a few participants who were from rural India, and when they were first aware of they’re experiencing some voices in in their mind or in their, you know, day to day routine. And when they conveyed it. The family member, the first thing that the family member did was reach out to religious treatment, like taking them to some tantric or, you know, shamans or whosoever who can help them with the voices because they believe that hearing voices means that you have been possessed by some kind of spirit. And maybe if the spirit is taken off your body, maybe you can get rid of those voices. So, the first preference for treatment was can also vary from culture to culture.

Rachel Star Withers: Yeah, no, that that’s really interesting. All those different parts. You brought up some stuff that I haven’t thought about. One of the last things you said there was talking about rural India

Nidhi Sinha: Mm-hmm.

Rachel Star Withers: Where they might have someone hearing a voice and think that they were possessed. Now, when you say possessed, is that seen as like a good thing or a bad thing?

Nidhi Sinha: From my interview with these people. So, majority of them, if I talk about, you know, in a quantitative term, it may be seen as a bad thing because being possessed over by spirit is something seen as bad. But there were many participants as well who were seen as that they are getting their spiritual awakening. Some kind of spiritual guide has taken over their body and they may have become spiritually awakened.

Rachel Star Withers: I asked that because I would say here in the West, when we hear the word possessed, it always means something bad. There is no good possession. I think you always have this idea of like a demonic satanic type thing.

Nidhi Sinha: So, it could be both good and bad thing depending on what kind of family that the person is coming from. So, some may see it as some kind of a spiritual awakening.

Rachel Star Withers: I’ve never thought of it that way. I like that. Now, when you say that, especially in India or Africa, some of the voices they hear are fun and more harmless. Can you give us an example? Like, what would be considered a fun voice? What are those voices saying?

Nidhi Sinha: So maybe the voice would be considered threatening when the person who is hearing the voices is hearing voices in their head, asking them to kill themselves or kill others or maybe physically harm others or themselves would be

Rachel Star Withers: Mhm.

Nidhi Sinha: The threatening. But if, say, about what could be a harmless voice hearing experience, it would be like when you are hearing voices of your family member and they are guiding you in your decision making process. So, I had one participant. She was a girl. She has recently lost her father. And after the death of her father, what happened that she started hearing voices of her father. T hose voices were what she said was very supportive and guiding. Whenever she would feel down, she would hear the voices, which would help her in giving her the inner strength.

Rachel Star Withers: How does the different content of these audio hallucinations affect the treatment then, for schizophrenia in these areas? How do they deal with these differently If the voices aren’t as threatening?

Nidhi Sinha: When you are talking about the content, there should be a difference in the, you know, treatment, the kind of treatment approach that has been taken. I’m putting an emphasis on should because that should happen. But it is actually not happening. We have to take into account that different cultures are shaped by their histories. And countries like India and Africa, they have had a history of colonization. So, most of the disorders which we see presently in India and other societies, may not be a product of genes or biological or physiological underpinning, but they may have a result of what we can say poverty and economic instability that may have been formed due to whatever happened in the past. We need to take into account that the culture of the indigenous healing practices also is present and they should also be acknowledged. But what happens is that in India, if I take about the example of my present research, I have talked to you about the girl who was hearing the voice of her father.

Nidhi Sinha: So, if you and I think it from a layman perspective, we’ll see that, okay, this voice is good. I mean, if the patient feels that it’s not something that is stressful for her, I mean, it’s okay to have that voice. But psychiatrist would disagree with me here because they would feel that it’s a symptom. Hearing voices is a symptom, is a classic symptom of schizophrenia or psychosis. And it is something that you need to get rid of. So, in the very fundamental understanding of the illness is very blurry when it comes to cultural differences, because when we talk about disorder, that the disorder is not only symptom based, it could also be experience based and phenomenology and unique experiences should also be taken into account when talking about treatment. So, to sum it all, it would be like treatment whether you hear a voice which is threatening or whether you don’t hear a voice which is threatening. At the end of the day, if you are reaching out to a mental hospital in India or anywhere, you would be encouraged to get rid of those voices rather than given an opportunity to accept and embrace that voices.

Rachel Star Withers: It’s a definitely a very interesting concept as far as. Yeah. How colonization forces a certain view of something. And especially when you’re talking about medical, you think how many like medical books and whatnot come from England, America and that kind of forces different diagnoses on people, whereas certain cultures might see them differently.

Nidhi Sinha: Yeah, exactly.

Rachel Star Withers: When you spoke about the caretakers, what type of role did you see them playing in the person with schizophrenia’s life?

Nidhi Sinha: That there is a high level of support that you get in India or in Africa as compared to the West, which can see both ways. Like you can see it as a good thing, also as a bad thing. Good thing. Why? Because somewhere down the line, if someone is hearing a voice and they know that there are people who are supporting them in their process of recovery, then it is a good thing. But most of the time what happens that these caregiver also comes with a rigid mindset that these voices are not good. What will happen that they would try to convince them to, you know, get rid of the voices? They would be giving them all sorts of different techniques which patient may not be needing at that moment, but they may feel over cared. I would like to use that term. Which may also impact their one-on-one relationship for in real life as well.

Rachel Star Withers: From these different studies that you’ve been involved with throughout your schooling, how do you think this is going to affect the way you become a doctor, the way you treat other people once you are fully a doctor?

Nidhi Sinha: For me, like I think one way in which these research are very instrumental in helping the future line of diagnosis and treatment is that there would be more awareness on holistic approach to treatment early. Right now, what is happening is that biomedical approach is in the forefront while the traditional healing practices. So, these kind of treatment are somehow treated as that they are inferior to the biomedical approach. So, maybe with these research, the training of the upcoming cohort of psychologists or the mental health experts would be different because then they will be acquainted with different kind of approaches that they can take into account when they are treating their patient or when they are giving any kind of therapeutic intervention. I think that these researchers or studies will be helpful in helping in policy changing in training, designing the training curriculum. And in future, maybe we may see more of a holistic treatment approach to treating illnesses, be it hallucinatory experiences or depressive symptoms.

Rachel Star Withers: I love that. I love the idea because, you know, not everybody experiences schizophrenia the same way. And there are so many different levels when you’re talking about the schizophrenia spectrum. And then, of course, moving across it throughout your lifetime. Schizophrenia changes so much from when I was a teenager to now when I’m in my late 30’s. You know, the complete ways of just treating myself, just looking at my own life has changed so much over those years.

Nidhi Sinha: Yeah. And because you are coming from a culture which is very different from Eastern culture, I think maybe like in the West, we you could also see that, you know, our traditional practices could be equally beneficial for the treatment of different illnesses. Maybe West will realize that there is a lot more for them to actually explore when it comes to treating and understanding mental health symptoms from Asian cultures as well.

Rachel Star Withers: I hope that you definitely continue down this path and we can learn more from you over time.

Nidhi Sinha: Yeah, sure. I’m really glad that, you know, you called me and you actually understood that culture is something that should be taken into account when we are talking about mental illnesses and especially schizophrenia and hallucinatory experiences. So, I think that is one way step toward advancing our knowledge about cultural experiences and maybe taking learning, collaborating with each other. You know, different cultures have so much to offer and maybe we can learn from each other. On how to improve the current state of art of treatment and diagnosis.

Rachel Star Withers: That’s wonderful. And I absolutely agree. Thank you so much for joining us today.

Nidhi Sinha: Thank you so much, Rachel, for having me over.

Gabe Howard: Rachel, as always, you did an excellent job. Do you agree with her observations on the differing content of the hallucinations across countries?

Rachel Star Withers: I found it very interesting. I kind of think it does have to do with a lot of the religious culture around and how certain things are framed. Whether you’re talking about Buddhism, Hinduism, Islam, you know, that really does go into you. And I think growing up around Christianity is a very white and black. It’s very God versus Satan, Jesus versus Satan. Demons are bad. So, if anything’s bothering me, it must be bad. And when you look at other religions, I think that can play into the fact that it’s not necessarily bad. I think most people in America. Okay, a spirit inhabiting you would be okay you’re possessed that you’re talking about demon possession. Right? That’s a horrible scary thing versus oh, you’re having a spiritual awakening. You’re connecting with your ancestors. Okay? You’re framing it that way. That sounds a lot better. I’m like, Oh, wow. Okay. Now both are psychosis, but I’m very I’m less scared of, oh, you’re having a spiritual awakening. And I think just the talk and culture around us, Yeah, it really affects how we respond and how people around us respond. If the people around me think I’m demon possessed, they’re going to act a lot different than if they think I’m having a spiritual awakening. Those little things can play such a huge difference into the stigma around the content of our delusions.

Gabe Howard: I think it helps us better understand ourselves, our loved ones and what’s happening with schizophrenia. And I think that can only be a good thing.

Rachel Star Withers: And we’re just scratching the surface. Clearly, this short podcast could not hit on all cultures and all things going on. Just within the US, we have different cultures. In different states you have different cultures. So of course, across the world we have so much going on. Cross-cultural understanding of psychiatric symptoms is important for us to understand our ever-changing global society. A lack of knowledge regarding cultural dependent manifestations is going to lead to misjudgment by clinicians, and you’re not going to get the appropriate treatment. The amazing thing, though, is that as the world becomes more open to us, we’re learning to look at serious mental disorders through a different lens that can help us all understand schizophrenia better and find new ways to treat it. Thank you so much for listening to this episode of Inside Schizophrenia. Please like share, subscribe and rate our podcasts and we’ll see you next time here on Inside Schizophrenia, a Healthline Media Podcast.
Announcer: You’ve been listening to Inside Schizophrenia, a podcast from Psych Central and Healthline Media. Previous episodes can be found at or on your favorite podcast player. Your host, Rachel Star Withers, can be found online at Co-host Gabe Howard can be found online at Thank you and we’ll see you next time.