Hearing distressing voices is a strong signal of potential mental health concerns and can lead to negative outcomes. Evidence-based practices to address distressing voice-hearing developed in western clinical settings may not be appropriate in sub-Saharan Africa. This study recruited patients who reported hearing voices at an outpatient clinic in semi-urban Arusha, Tanzania. Forty-three participants consented to the study and reported hearing auditory verbal hallucinations, including 88% (n = 38) reporting distressing hearing voices. The sample was split by gender, representative of a range of ages and included a primarily Maasai-related, Christian and unmarried sample with limited education. Ninety-one percent (n = 39) met criteria for moderate to severe psychopathology (Kessler-10-Swahili). Qualitative interviews (n = 43) revealed how this sample thought about mental health, how they experienced and explained their voices, and their pathways to care for help with mental health concerns that arose from their experiences. People who heard distressing voices typically approached religious healers first, but had a strong preference for biomedical care, attributed both biomedical and social causes to their symptoms, believed that voice-dialoguing practices endorsed in the west could signal participation in witchcraft, and had few resources to engage in multi-session, professional-led or high-tech interventions currently being used in Euroamerican contexts. In this region, patients with psychosis symptoms relied on and trusted family, religious leaders and biomedical treatment providers for support with their mental health needs. Networking the three together for persons experiencing psychotic symptoms could create a sustainable resource for long-term follow-up and mutual support.