‘Graphic Medicine’ as a Mental Health Information Resource: Insights from Comics Producers

Recent literature suggests that a growing number of comics are being published on health-related topics, including aspects of mental health and social care (Williams 2012; Czerwiec et al 2015) and that comics are increasingly being used in higher education settings as information resources. This article offers insights from comics creators and disseminators and explores the wider context of comics production and distribution (with a focus on 'Graphic Medicine' or health-related comics) as part of a larger examination of the interface between these documents and potential academic audiences. Original data was gathered through semi-structured interviews with 15 participants actively involved in comics creation and production. Elements of domain analysis (Hjorland 2002) were used to obtain insights into attitudes to the creation, dissemination and use of mental health-related comics. Though potentially useful comics material is being produced in the mental health domain, significant challenges remain for producers in enabling their work to be accessed within higher education settings. This paper suggests that comics producers need to make a concerted effort to reach academia, and academia - including information professionals - need to embrace new types of material to enhance teaching.

The history of comics and the so-called ' definitional project' (Groensteen 2007: 379) are beyond the scope of this paper. However in seeking material to explore for this study, we are guided by Williams use of the term ' comics' 'in the plural to refer to both the physical objects and the attendant philosophy and practice surrounding them' from his 2012 Medical Humanities article (2012: 21); and McCloud's definition of comics as: 'juxtaposed pictorial and other images in deliberate sequence, intended to convey information and/or to produce an aesthetic response in the viewer' (McCloud 1993: 9). Employing McCloud's definition proves useful as it expresses both the form and function of comics as information objects. It also draws the distinction between comics and illustrated books, which generally use images in isolation and often for affective purposes, rather than for narrative progression. Madness and Civilization (1971), talking of ' a circularity of discourse' around mental health while recalling her own psychiatric treatment for borderline personality disorder, and stresses the importance of 'patients' voices being heard' (Godfrey and Mould 2014). A potential educational use of graphic pathographies could therefore be to 'help healthcare workers understand the nature of personal narrative, and hence may lead to a more considerate and enlightened attitude when dealing with the patient's history' (Williams 2012: 26). This use would also seem to support Charon's assertion that a person's narrative of illness is not just told through 'linear prose but in gesture, movement, happenings in time' (Charon 2005: 262). According to Squier, 'graphic narrative has the capacity to articulate aspects of social experience that escape both the normal realms of medicine and the comforts of canonical literature' (Squier 2008: 130).

Cultural Stigma
If graphic narratives have demonstrated therapeutic utility, why then have they not been more widely promoted within health and social care education? Despite claims of the utility of comics, the wider cultural stigma attached to them as being devoid of academic or intellectual value cannot be ignored (Aleixo and Norris, 2010: 2).
Botzakis provides a case study where an adult comics reader approaches them as a 'thoughtful activity' but ' does so undercover, afraid of censure' (Botzakis 2011: 122).
This problem might be greater in the context of psychology and social care education because, in mainstream superhero comics at least, when ' contemporary psychiatric terms or disorders have been used in stories, they have been misapplied to explain villainy' (Bender et al. 2011).
Williams proposes the influence of underground comics and claims 'graphic memoirs trace their genealogy to the products of the counterculture of the 1960s and 1970s (2012: 21). Freedman also sees practices around comics production and distribution as stemming from the underground comics scene and creating ' a culture of connoisseurship and fandom' (Freedman 2011: 37). He also describes how this cultural space 'not only challenges the border between high art and popular culture According to Brienza, all manifestations of culture are 'the products of a complex, and often formally organized, network of social interactions' (Brienza 2010: 107).
Dittmer notes that those in the retail sale and distribution of comics are often enthusiasts and ' are directly embedded in webs of social interaction with other readers and have particular understandings of readers' interests and responses' (Dittmer 2010: 225). Murray also sees this sense of community manifest in online comics and sometimes serving a surrogate editorial role for self-publishing creators as digital publishing disrupts traditional structures. (Murray 2013: 341).
It is in this cultural context, informed by the background of comics production and comics scholarship as discussed above, that our interviews with Graphic Medicine producers proceeds.

Methods and Limitations
This paper considers only works published in English and/or English-speaking, mostly UK-based authors. To establish how aspects of the comics industry work in relation to the concepts of creation and dissemination in the context of the 'information chain' (Robinson 2009), 15 semi-structured interviews were conducted with participants The creators and disseminators interviewed have two main functions in the communication chain: as 'sources' and/or 'providers' of information products (Robson and Robinson 2013: 185). By discussing some of the motivations and processes behind these information products, we hope to gain insight into the types of documents they produce and analyse any potential uses they may have in the context of mental health training.
In relation to the use of semi-structured interviews, Oates states that one of the disadvantages of the method is that 'the effect of the researcher and the context means that consistency and objectivity are hard to achieve' (Oates 2006: 198). Oates are not usually suitable for circumstances where you want to make generalizations about a whole population' (Oates 2006: 199). In this case however, the advantages of using semi-structured interviews outweighed the disadvantages, given that the creators and disseminators involved in 'Graphic Medicine' and related circles in the English-speaking world is still a network easy to circumscribe.
We conducted the interviews through different interfaces -in person, by phone

Motives for Creation
The motivations for producing graphic narrative works expressed by interviewees varied, including the need to share a story, to help patients, and providing informational value. For Williams, the OCD (Obsessive Compulsive Disorder) aspect of his graphic novel The Bad Doctor (Williams 2014) was included because he 'thought that would make a good story' although that element is 'semi-autobiographical'. Williams had self-published work before he created The Bad Doctor for Myriad Editions and his independent work ' all ended up with some kind of autobiographical element, even though you change and disguise patients and change experiences. But, inevitably, a lot of the action is based on some sort of kernel of truth.' In the production of Episodes of Schizophrenia (Robinson and Leach 2012), artist Leach did not set out to produce a text to educate professionals, but rather a book to help 'friends and family of sufferers, and someone who's been diagnosed with a Burrowes described her illustrated work as The Cartooning Psychologist as removing the barriers between professionals and patients. Burrowes prefers the term ' cartoon' to ' comics', and pointed out she is 'not trying necessarily to communicate with the established graphic-novel sector'. However, her book The Courage to be Me (Burrowes 2014) is a graphic narrative that fits the definition of comics as defined for this paper. Its primary audience is not mental health professionals, but Burrowes described it as being potentially useful to them. Burrowes suggested that while the concept of the talking cure is the predominant therapeutic paradigm and helpful for many, alternatives should be explored. Bloomfield also said that alternative modalities should be part of practice, and saw her writing in the fictionalised graphic narrative Couple Therapy (Bloomfield and Radley 2013) as having practical value to trainee therapists by depicting some of her techniques for working in sessions with clients.
Barker described comics as an opportunity 'to cut through the standard narratives that people tell' with implications for the therapeutic process. She hasn't used comics during therapeutic sessions with clients, but does incorporate them as a complement to her written work, including a comic strip in every chapter of her monograph Mindful Counselling and Psychotherapy (Barker 2013). An example of this can be seen in Figure 1: while advocating the use of mindfulness, Barker wanted to depict how unwelcome thoughts and memories can intrude and she believed comics provided the best way of conveying the point.

Processes of Creation
Williams saw the role of the publishing team at Myriad Editions as essential in helping him shape his graphic novel The Bad Doctor, especially editor Pearlman. Pearlman outlines the process as follows, further emphasising the complex collaborative nature of the enterprise: 'The Bad Doctor. . . went through many, many drafts before we found the form of interspersing the patients' stories with those of the doctor's past, and with episodes from the cycling trips he takes with his friend to let off steam! . . .
And it was only when we were very near the deadline of the book that the ending was sorted -thanks in no small part to the copy editor who of course is the crucial next stage in a book's production, once the author and editor have done their business.' According to Williams, health-related comics produced within a self-publishing model are capable of producing work that has its own unique value as 'raw material'

The Influence of Peer Networks
Czerweic, co-manager of the GraphicMedicine.org website, also sees the concept of finding like-minded people at the core of the group's activities, stating 'in some ways, the community building, and the kind of community that was formed around the website Ian Williams created and the first conference he held in 2010 in London, that's been the biggest prize' (Fitch, 2013).  Bowler believed that the influence and function of social media is more apparent in comics publishing than in any other form of book publishing. Rigby also argued that comics fostered a unique level of interaction between creators and audience, online and offline. This culture has led to an expectation on the part of publishers that all creators will be engaged with their audience on social media.
As well as the connections with an audience, the connections between creators could influence the shape of the small-press comics sector with Walsh anticipating '. . . a lot of micropublishers and collectives forming that will allow creators to collaborate in terms of publishing and distribution as much as creating the comics themselves.' Links beyond the established comics community are also being fostered, as noted by Stringer-Horne as she recalled outreach work done by the Thought Bubble comics festival that involved aspects of social care and graphic narratives: We work with refugees and the Leeds Autism Services and do things throughout the year with them, and we always do a big project every year that's funded. . . We've worked with the Bradford Refugee Centre and I think it was last year, we did a project with them. . . We use an art therapist on all of our projects, and she helps craft comics that help them explore their stories, their emotions and stuff that came out of their status in the UK and their journey.

Modes of Distribution
Bowler saw some aspects of the cultural and retail environment as now potentially favouring graphic narratives, both in terms of mainstream publicity and the promotional potential within the existing fandom. However, Gray was more cautious and saw graphic novels as ' a specialist line of publishing -in a bookshop there will be a single section with everything in it from superhero comics to serious fiction. So they carry significant sales risks.' According to Bowler, one disadvantage distinct to the form is that 'these are expensive books to make, but they're actually relatively quick reading experi-  According to Pearlman, Myriad does undertake some academia-focused marketing and the publisher does 'try and promote specifically to relevant academics' but awareness of the academic landscape is a problem: 'Academic marketing is something that definitely needs to be worked on within our own organisation, and authors who aren't part of the academic circuit need to be introduced to the academic departments that would be interested in their work.'

Interactions with Academic and Health Institutions
Arthur stated that coverage of Nobrow's Neurocomic had been limited in the UK academic press: 'I think we had a mention in Nature [Kiser 2013] and also The Lancet Both retailer participants in this project offer services to libraries although neither had any interaction with higher-education institutions. Walsh, from Gosh!, stated that all the shop's 'library orders come from local authorities for high street libraries'. He had 'presented to librarians recently on comics suitable for teens but, again, that was for a local authority rather than an educational institution'.
Rigby told how of how public library orders had dried up in recent years and speculated that budget cuts might be the cause, although Page 45 does have customers for its library service. Rigby recalled attempts to engage with highereducation institutions but with little response. Wider misconceptions surrounding comics were described by Rigby as a possible explanation for the lack of interest from academia: . . . just immediately after World War Two, where superheroes became so popular -they subsumed the comics' medium, from the public perception.
. . . So it's not necessarily a barrier that's set within higher education.
I think it's just that it's equally as prevalent there as it is among the public at large. . . . So I think it almost needs to come the other way really, from those within higher education, who have an interest in the medium, promoting it to their colleagues.
Bloomfield reported her comics work had been received negatively by some fellow professionals in mental health and Burrowes argued that any scepticism towards her illustrated work is misplaced and could be resolved with exposure. Burrowes saw her work as part of wider professional imperative for making treatment as accessible as possible and believed this should be more widely adopted by researchers and professionals.
Walsh believed there is evidence of a shift in academic perception already happening: The traditional view of comics as not being of academic worth is the biggest barrier but this seems to be improving all the time. The more comics are accepted, the more publishers are willing to invest in comics that are of value to academics, which in turn leads to comics becoming more accepted.
It's a virtuous circle! Lowther from the Wellcome Library recounted an example of his institution interacting with a comics retailer via a presentation he made at Gosh!, helping create awareness of the Wellcome Trust within attendants belonging to the comics community.
Barker has not yet used comics much in her teaching work at the Open University, but said 'we do use cartoons quite a lot, more in a breaking up the text and illustrating things humorously kind of way'. She suggested that part of the reason for the lack of use of comics in teaching psychology could be that their pedagogical function may not immediately be obvious: '. . . maybe part of the problem was because I was classifying quite a small, narrow band of comics as mental health comics, because if you think about it, a comic like Maus [Spiegelman 1986] is actually about mental health in its broader sense -it is about the effect of trauma through generations'.
Barker did state that she could now see the possible application of comics in teaching, particularly memoirs.
Several participants stated that books they'd been involved with had been used in academic or training contexts. Bowler did not believe any Jonathan Cape titles had been used ' as teaching guides' but were more likely to be ' a text to study'. He added that texts becoming adopted on reading lists ' can be extremely lucrative'.
Bowler also speculated about whether the cost of graphic narratives might have an effect on their adoption as set texts, and why this might be an opportunity for digital distribution. Rigby took a similar view: 'I can actually see a way, especially for the classroom, where actually digital distribution of those might be ideal.' Although it is not currently used for distribution of material to educational institutions, Pursey described how the Sequential app does have such capability. However, Pursey did also mention that copyright restrictions would have to be considered before the platform would be practical for library or educational uses.

Discussion
The analysis of motivations for comics production revealed that mental health professionals such as Bloomfield, Burrowes and Barker share a desire to move away from medicalised framing of people's treatment or suffering -in line with questions raised on whether medical models can ' explain and cure ills and relieve suffering' (Hydén 1997: 49). Perspectives from those living with mental health conditions, such as L.B. Lee, or produced by lay-person sympathisers such as Leach, are also seeking to provide insights that might be missed by the functionality of diagnostic approaches and the resulting public perception that can be influenced by them.
Whether these accounts might be autobiographical or fictionalised, all seem to be seeking to provide information that can help 'understand illness. . . as a social, political, and narrative construct' (Green 2013: 472). Although exactly what type of information this represents and its value to professionals is open to debate, especially when compromises are made on ' accuracy and precision for personal meaning' (Shapiro 2011: 71), by producing graphic narratives authors are potentially contributing ' different kinds of evidence from that offered by scientific experiments' (Charon 2006: 194). It is possible, then, that their work can have a pedagogical function and value in the context of mental health training.
Links between the process of comics creation and a 'network of social interactions' (Brienza 2010: 107)  Freedman's conception of comics culture obscuring the distinctions between formal and informal specialisation (Freedman 2011: 29) seems to be tangible in the above processes and is also visible in the dissemination stage of the information chain. Among other retail activities, on admittedly contrasting scales, self-publishers such as L.B. Lee and established publishing houses such as Jonathan Cape use comics-specific events like conventions and fairs to make sales, and these gatherings also influence the creative process, either with feedback from fans, customers and fellow artists, or from publishers looking for new talent.
Freedman's description of how the nature of comics ' confounds the distinction between academic and amateur scholarship' (Freedman 2011: 29) also could go beyond the domain of comics studies and into any discipline where comics become central to the discourse. There seems to be an almost comic-con culture informing at least some aspects of academic conferences such as the International Conference on Comics and Medicine series -illustrated, literally, by the organiser Al-Jawad's fullpage cartoon depicting a scene of numerous social interactions (Al-Jawad 2013: 146), and also suggested in comments like Czerweic's on the event's community building being the 'biggest prize' (Fitch 2013). This is not meant to infer these gatherings are anything less than serious academic enterprises, but to emphasise that to fully understand the value of comics to mental health training, it is necessary to understand its community's contribution to the information chain. This claim is justified by the evidence provided by the interviewees, who agreed in the key role that the community plays in comic book culture in general and mental health-related comics culture in particular. This suggests that, for comics producers and disseminators, the published book (the 'text') is only one element in a complex information chain.
This has implications for the full understanding of the relevance of contemporary Graphic Medicine, particularly when approached from vantage points not familiar with comic book culture and its particularities.

Final Reflections
Creators and publishers reported some academic use of graphic narratives, although no evidence was produced to confirm that they are indeed currently used as informative texts or aids to study. The type of material being produced is varied, and so are the circumstances of production. It is likely there would be a perceived reassurance about comics produced by established publishers as far as libraries and higher education institutions are concerned. However, this perception not only excludes the work of established self-publishing psychologists such as Burrowes, but it also excludes work by authors such as L.B. Lee, whose work embodies the experiences of living with multiple personalities in a way that only comics can (see Figure 2). There is the potential to miss valuable and informative material if comics work by dedicated practitioners or passionate advocates are to be ignored because their chosen mode of expression comes from beyond those traditionally accepted.
Analysis of the data generated by these interviews also suggests that, to fully explore or realise the potential of comics in the context of the mental health domain of academia, firmer links need to be established between comics producers and their potential users. Producers must make a concerted effort to reach academia, and academia must embrace new types of material to enhance teaching. Importantly, it is vital that librarians and information professionals demonstrate an interest in forging