Clinical Perspectives

State of the Medical Community’s Knowledge

Tulpamancy, like most forms of plurality, has not received much research attention from academics or clinicians. The only types of plurality that have had much formal research are DID (Dissociative identity disorder – formerly known as MPD) and OSDD (other specified dissociative disorder, formerly known as DDNOS). It is currently unknown and hotly debated how much of that research actually applies to other forms of plurality such as tulpamancy – however, the research would likely be applicable to those who have DID/OSDD and have also made tulpas. There has been a some research into soulbonding and soulbonding-like phenomena (though not described using those terms) and a tiny bit into tulpamancy, the latter primarily from an anthropological standpoint.

Given this state of research, there isn’t much of a well-defined clinical perspective on tulpamancy. Because there isn’t much directly applicable research for them to go on, clinicians and academics tend look at tulpamancy through the lens of things that have been studied and/or work out their own perspective of it. In other words, your and your tulpas’ reception will vary when it comes to talking to therapists and other medical professionals about tulpamancy.

Why On Earth Would I See a Therapist or Tell Them About Tulpamancy?

For one, one might already have a therapist for other reasons – depression, anxiety, etc – and find that tulpamancy is relevant to those reasons. For example, a mental health situation, condition, and/or disorder may affect different members of the system differently. Another reason may be to address interpersonal difficulties, clashes, etc. between system members that have come up. Others in a system may be able to benefit from counseling as well, increasing the overall health of the system. A prospective tulpamancer may also be unsure how tulpa creation would be affected by or affect a mental health situation, condition, and/or disorder they already have.

A particularly significant reason would be if after making one or more tulpas, a mental health situation, condition, and/or disorder begins, comes to light, etc. or some problem comes up directly concerning the system’s plurality. In addition to interpersonal conflict between system members, it is possible for being plural itself to become a source of distress or dysfunction. For example, someone may front and become “stuck”, or switching may become otherwise uncontrolled. There may be outerworld forgetfulness caused by poor memory sharing and/or communication of important things between the different system members controlling the body. Or someone in the system might develop dissociation problems (uncontrolled derealization, depersonalization, etc.). While such experiences tend to be rare among tulpamancers, they are not unheard of.

It is also possible that someone else could have found out about a system’s plurality and forced them to see a therapist about it. Unfortunately, laypeople can often assume the worst with regards to plurality.

For any number of reasons, sometimes a system wants or needs to tell a therapist about their plurality. A good therapist can be a very useful resource and provide a lot of help for a variety of things, whether plurality-related or not. There are many situations where it could be wise to seek one out.

Some Words of Caution

Therapists are not a homogeneous group. A good therapist can be a great help. The wrong therapist can stall recovery or, at worst, worsen an existing problem. If one needs or wants a therapist, it is wise to exercise some care and to test the waters before outing oneself as plural. Try to find out what information they have regarding plurality and their attitudes regarding tulpamancy. Sometimes, one realizes one has the wrong therapist. There is nothing wrong with changing therapists in that situation. Note that advice is sound advice for finding a therapist or dealing with an existing one with regards to any mental health situation, condition, and/or disorder – just change the words. Tulpamancy and/or plurality are not special in these regards.

Most information found online regarding the experiences of plural systems, especially non-DID/OSDD systems, with the medical community paints a very bleak picture – views of plurality as being inherently disordered, integration seen as the only recourse, systems pressured into integration or threatened with involuntary commitment. However, a lot of the information available, such as that on Astraea’s Web, was written about experiences with the medical community in the 1980’s and 1990’s. Fortunately, the situation has changed. The medical community has become much more enlightened in the intervening decades. When researching plurality, always keep in mind the date/s that information is based on.

There are still several specific things to be cautious about.

Out-of-Date Therapists

Some therapists are working with out-of-date information and knowledge. This most commonly happens with therapists who are specialized in one area but find themselves having to deal with things in another area. Most therapists concentrate their efforts on staying up to date in theirs fields of specialty, not the others. However, it is also possible for a specialist to be out-of-date in the area of their specialty as well.

When selecting a therapist, ask them about what they base their practices on. For example, you could ask them which version of the DSM (Diagnostic and Statistical Manual of Mental Disorders) they use. The current version, as of 2016-01-01, is the DSM-5 (also known as the DSM-V). If a therapist says they use say the DSM-III, then they are very out-of-date and should be avoided. (This does not necessarily mean that the newest version is perfect. Many therapists, including many good ones, will likely disagree with the DSM on a number of points, and the best therapists will adjust treatment to suit the client rather than the book. This is true for any type of medical professional)

Ask them what their views on plurality are. If they believe that it is innately pathological no matter the system’s feelings or state of functionality, and that it must be “fixed” by integrating/merging/fusing all members together, and that this must be done before any other mental health issue is addressed, then they are extremely out-of-date. After all, if a system struggles with anxiety but does not have any other problems, then such an approach would fail to address the actual mental health problem at hand and could possibly cause additional health issues for the system. A more modern view is to analyze the functioning of the system and work on the problems they are dealing with while leaving other things be, with integration being an option decided by the system rather than a requirement.


Therapists often have to give a diagnosis of some kind. Health insurance and social medical systems often demand a diagnosis of some sort to make sure, in their eyes, that the treatment given is actually needed and not a waste of money. Giving a name to a disorder also makes it easier to discuss it with other medical professionals at later dates, access treatment if warranted, etc.

But the wrong diagnosis can cause problems. One could undergo the wrong treatment or otherwise suffer consequences due to an unwarranted diagnosis.

It is quite common that an initial diagnosis will later be adjusted upon uncovering more information. It is actually because of this that the DSM-5 split up the previous NOS (Not Otherwise Specified) categories into OS (Other Specified) and US (Un-Specified) categories. The former applies to disorders that almost fit another designated disorder, but not quite, and the latter applies to that which seems to be a disorder of some variety but which needs more information for a more exact diagnosis, with the implication that this could be a temporary diagnosis.

When tulpamancy is brought up (or other forms of plurality), certain specific misdiagnoses are possible. DID (Dissociative Identity Disorder) and OSDD (Other Specified Dissociative Disorder) are two common ones that tulpamancy systems have to be concerned about. The diagnostic criteria for these disorders is given at the end of this page. A therapist specialized in Dissociative Disorders is less likely to give such a misdiagnosis than one not specialized in them.

Most pure tulpamancy systems do not meet the diagnostic criteria for DID, namely due to lacking a high level of amnesia when system members exchange bodily control. However, a pure tulpamancy system would meet the DSM-V’s diagnostic criteria for OSDD if they meet the criteria for being disordered (more information given at the end of the page). This is often considered to be a flaw in the diagnostic criteria due to the medical community mostly having experience with systems who were created by trauma (called traumagenic), who often suffer dysfunction linked to their trauma. The establishment has had less interaction with naturally-arising systems (called natural systems or endogenic systems) and created systems such as tulpamancy systems. There is great debate about whether such diagnostic labels should apply to non-traumagenic systems, even if they meet the criteria, due to the very different origins of their plurality. In other words, whether the criteria should be revised and new diagnoses created for non-traumagenic systems who would meet the criteria as they are currently written. Further complication arises when one looks outside the strict diagnostic guidelines to the DID/OSDD community itself, where there are systems who identify as and are diagnosed as DID, but do not experience their plurality itself as being problematic. Rather, they are given and identify under the diagnosis because their plurality is irreversibly and profoundly interwoven with their trauma, and thus any trauma work they do must involve their plurality.

Thus, what it means to have DID/OSDD is not as clear-cut as it might seem. There is no end of gray areas and blurry lines. A full discussion of this, however, is not the topic of this page–for the sake of this topic, we will be focusing solely on the matter of formal diagnosis, and what is in the DSM.

A misdiagnosis of DID or OSDD could have certain consequences, namely due to assumptions people have about people with such diagnoses, as well as the real issues faced by people who fit them. For example, a diagnosis of DID (and more rarely OSDD) can have the following legal consequences, many of which are general to diagnoses of “severe” mental illnesses:

  • Losing one’s driver’s license or having difficulty obtaining one, or having to go through psychotherapy and/or a medical board just to prove you can have one.
  • Losing custody of children and being barred from adopting.
  • Being barred from certain jobs (for example, jobs that require security clearance).
  • Being declared incompetent (losing the right to make one’s own medical, legal, and financial decisions).
  • For those systems undergoing or trying to start a gender transition, it can be used as a reason to block access to hormones, surgeries, name changes and legal documents, etc.
  • Being involuntarily committed (especially for those systems below body age 18 whose legal guardians do not react well) and forced to attend therapy, to take anti-psychotics, and/or to integrate.
  • Can be used as a reason to fire a system and deny them benefits in many legal jurisdictions.
  • Can be used as a reason to evict a system from their residence in many legal jurisdictions.

It is also important to note that these diagnoses can be part of one’s permanent record.

Being misdiagnosed is not a non-issue – such diagnoses can have real-world consequences. Be especially wary of out-of-date therapists in this department. Ask a potential therapist early about their thoughts on giving and revising diagnoses and their thoughts on what constitutes a disorder. If you are seeing a therapist primarily for a problem not related to plurality, then there is the possibility that they could just record those and leave the plurality out of the official record unless you really do fit such a diagnosis.


There are many reasons why a tulpamancy system might need or want to see a therapist, or bring their plurality up with an existing therapist. A good therapist can be an indispensable resource in dealing with mental health situations, conditions, and/or disorders. As with any situation where one would seek a therapist or bring something new up with an existing therapist, one should exercise some caution and research, ask questions, etc. so as to not end up with an out-of-date therapist, a misdiagnosis, or poor treatment. Remember, therapists are not one-size-fits-all, and it is OK to change therapists if necessary.

Finally, exercise caution, not paranoia. If you need a therapist badly, don’t let fear hold you back from getting help. Keep in mind that, while psychiatry has a long ways to go with plurality, things have improved, and while you still may need to ask probing questions and shop around, it may be more possible than you think to find someone who will respect you and your system.


Diagnostic Criteria – DID

From the DSM-5

Dissociative Identity Disorder

  1. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
  2. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
  3. The symptoms cause clinically significant distress or impairment in social, occupa­tional, or other important areas of functioning.
  4. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
  5. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Diagnostic Criteria – OSDD

From the DSM-5

Other Specified Dissociative Disorder

This category applies to presentations in which symptoms characteristic of a dissociative disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the dissociative disorders diagnostic class. The other specified dissocia­tive disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific disso­ciative disorder. This is done by recording “other specified dissociative disorder” followed by the specific reason (e.g., “dissociative trance”). Examples of presentations that can be specified using the “other specified” designation include the following:

  1. Chronic and recurrent syndromes of mixed dissociative symptoms: This category includes identity disturbance associated with less-than-marked discontinuities in sense of self and agency, or alterations of identity or episodes of possession in an individual who reports no dissociative amnesia.
  2. Identity disturbance due to prolonged and intense coercive persuasion: Individuals who have been subjected to intense coercive persuasion (e.g., brainwashing, thought reform, indoctrination while captive, torture, long-term political imprisonment, recruitment by sects/cults or by terror organizations) may present with prolonged changes in, or conscious questioning of, their identity.
  3. Acute dissociative reactions to stressful events: This category is for acute, transient conditions that typically last less than 1 month, and sometimes only a few hours or days. These conditions are characterized by constriction of consciousness; depersonalization; derealization; perceptual disturbances (e.g., time slowing, macropsia); micro-amnesias; transient stupor; and/or alterations in sensory-motor functioning (e.g., analgesia, paralysis).
  4. Dissociative trance: This condition is characterized by an acute narrowing or complete loss of awareness of immediate surroundings that manifests as profound unresponsiveness or insensitivity to environmental stimuli. The unresponsiveness may be accompanied by minor stereotyped behaviors (e.g., finger movements) of which the individual is unaware and/or that he or she cannot control, as well as transient paralysis or loss of consciousness. The dissociative trance is not a normal part of a broadly accepted collective cultural or religious practice.

Defining Disorder

What exactly constitutes a mental disorder? It turns out to be non-trivial and something that the mental health community has been working on for decades.

To quote directly from The Quandary’s website:

In order for something to qualify as a mental illness, a behavior must fit at least two of the 4Ds of abnormal psychology, which are:

Deviance: this term describes the idea that specific thoughts, behaviours and emotions are considered deviant when they are unacceptable or not common in society. Clinicians must, however, remember that minority groups are not always deemed deviant just because they may not have anything in common with other groups. Therefore, we define an individual’s actions as deviant or abnormal when his or her behaviour is deemed unacceptable by the culture he or she belongs to.

Distress: this term accounts for negative feelings by the individual with the disorder. He or she may feel deeply troubled and affected by their illness.

Dysfunction: this term involves maladaptive behaviour that impairs the individual’s ability to perform normal daily functions, such as getting ready for work in the morning, or driving a car. Such maladaptive behaviours prevent the individual from living a normal, healthy lifestyle. However, dysfunctional behaviour is not always caused by a disorder; it may be voluntary, such as engaging in a hunger strike.

Danger: this term involves dangerous or violent behaviour directed at the individual, or others in the environment. An example of dangerous behaviour that may suggest a psychological disorder is engaging in suicidal activity.

Honestly, Deviance is a moot point when it comes to a lot of mental diagnoses, given cultural variation and the whole arbitrary nature of normality in the first place. I think it’s in there just so culturally accepted dangerous practices like binge drinking and so on don’t get pushed under mental illness. If someone ever says that X activity is “mental illness” simply because it’s “not normal”, they don’t know what they’re talking about. (Sadly, this includes some psychs.)

So basically, for something to be counted as a mental illness, it must be one of the last three Ds. And even that is very arbitrary. Clearly, suicidal behavior and self-harm are indications of something being seriously wrong. But a lot of stuff lies in a gradient between the extreme and the “healthy”, and it’s impossible to draw exact lines and assign exact values and say “this must be THIS distressing/dysfunctional/dangerous to be considered mental illness”. It’s going to change depending on the context and who you talk to. I mean, I get really tied up mentally if some things aren’t in a row and it’ll make my head a mess until I fix it up. Does that make me mentally ill or quirky? (I’m talking about a kind of mental tie-up distinct from what I get with OCD.) Not even going to get into double-standards regarding mental illness vs eccentricity, and how arbitrary definitions of “functionality” can be. Not to mention how it is actually quite rare to have a problem-free life.

In addition, the DSM-V has, near its introduction, a paragraph explicitly defining mental disorders:

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.