1.1 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 psychotic episode’. Leach describes her motives for choosing to illustrate some of the writing of schizoaffective disorder sufferer and advocacy campaigner Jennifer Robinson (www.suicidalnomore.com) as emerging from personal contact with people who suffered in a similar way.

Educating people on what it is like to live as part of a multiple-personality system – described as ‘dissociative identity disorder’ in DSM-5 (American Psychiatric Association 2013) – was central to L.B. Lee producing comics works such MPD For You and Me (L.B. Lee 2007). Although the comics avoid the idiomatic terminology of professional discourse, L.B. Lee saw them as having informational value to mental health practitioners.

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.

Figure 1

‘No wonder my back hurts’ (Barker, M. 2013: 34). © Meg-John Barker 2013.

1.2 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’ and ‘sources of knowledge’, distinguishing them from longer form, commercially ambitious projects where ‘you want to get it published or sell it, then I think that you probably do need an editor’s input.’

Bowler on the other hand described the editorial team’s role at Jonathan Cape as one concerned with initiating and establishing negotiations with the author and with ‘structural editing’, contributing to the ‘story’ element of the books, not their ‘aesthetics’. This demarcation of competencies outlined by Bowler had similarities with the processes at Nobrow as described by Arthur for the neurobiology comic book Neurocomic (Farinella and Roš 2014).

Leach saw the historical legacy of self-publishing as giving voice to groups that might be excluded from commercial processes, and Burrowes likened the restricted amount of text that can be used in comics and cartoons to the concision required by a social media platform such as Twitter, suggesting a distinct discipline to the comics writing process.

While Burrowes is able to write and illustrate much of her work, Bloomfield worked with an illustrator on Couple Therapy and said this had implications for the process: ‘If you can’t draw yourself, like me, you have to give up your own images. In any collaboration, you have to give something; you have to compromise.’ Bloomfield also suggested there is another area of compromise that needed to be negotiated while attempting to represent the therapeutic process in the book:

I suppose there was a tension between the dramatic, what I saw as the dramatic needs of the stories, and the actual process of counselling, which is very slow…So really, counselling is like layers and layers of meaning being peeled back…But drama is not like that really. Drama is an external state, often, and visual drama is externally driven by events.

Gray stated that compromises that may be demanded by the comics form don’t necessarily preclude it from pedagogical use: ‘A comic inevitably sacrifices some academic detail for visual impact – that is the trade-off. So they need to be used as one of a variety of tools, but that’s the case with most teaching resources anyway.’

1.3 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). This position is echoed in a letter to the journal Medical Humanities, as Al-Jawad summarises the 2013 International Conference on Comics and Medicine using a full-page drawing with cartoon representations of those who took part (Al-Jawad 2013: 146). Al-Jawad also describes the ‘open and friendly atmosphere’ with a ‘marketplace where many artists were able to show and sell comic books of all shapes and sizes’ (Al-Jawad 2013: 145).

The perception of community was apparent in most of the interviews, although the concept and its components varied. Activities around comics fairs such as Thought Bubble (http://thoughtbubblefestival.com) in Leeds and creator-focussed meetings such as Laydeez do Comics (http://laydeezdocomics.wordpress.com) are seen as integral to this sense of community. Williams identified social interactions around comics as providing an environment that facilitated self-expression. While Williams’ recollection of his early trips to comics fairs and conferences seem to exemplify an informal atmosphere with little consideration of commerce, he also pointed out that connections made during this time later led to professional work.

Pearlman stated that comics conventions and fairs are ‘absolutely vital’, for creators and publishers alike, and Bowler agreed with the importance of conventions and fairs to publishers, and suggested that Jonathan Cape could learn from Pearlman and Myriad’s approach. L.B. Lee described conferences and festivals as a way of getting ‘more direct feedback about our work’ and providing the opportunity to ‘meet up with other creators who can give valid input’.

As a festival coordinator of the Thought Bubble comics festival, Stringer-Horne stated that ‘the biggest thing that it gives is that it’s a really great networking opportunity for creators and for publishers’, including the opportunity for creators to have ‘portfolio reviews’, ‘find new fans’ and participate in ‘sharing all their techniques’.

As well as the in-person interactions at conferences and fairs, online social networks are seen as vital by many involved in comics creation and distribution. Williams described Twitter as ‘probably instrumental in forming connections within the comics community’ although he did not find online interactions a useful source of constructive criticism. Stringer-Horne agreed that social networks were less likely to have an effect on a creator’s content than a positive effect on their productivity: ‘social media – especially Twitter, where most of the comic creators talk to each other – that’s a really great lifeline back into the community.’

Beyond Twitter, Stringer-Horne gave examples of how she believed other social media networks, such as Instagram and Tumblr are also proving useful for expanding an artists’ audiences and improving their reputation. However, she also articulated how heightened levels of expertise and a close-knit community can be intimidating.

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.

Although Barker does not see herself as ‘an insider in this world’, her professional activities have still intersected with the worlds of comics and fandom at the Nine Worlds GeekFest (https://nineworlds.co.uk) where she did a successful workshop on comics getting people to talk about their experiences.

2.1 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 experiences’. Although working to a different model and price point, Burrowes saw it as an advantage that ‘you can read most of my books within 15 minutes’ adding that ‘it’s kind of beautiful but it’s also really damn clever’. Burrowes has self-published the books on the Amazon CreateSpace platform (https://www.createspace.com), producing print-on-demand copies of The Courage to be Me. This meets readers’ requests for physical copies even though the book is free to read on her website.

L.B. Lee said that as well as selling comics online, direct sales are also made at conventions and provide some market data. Bloomfield reported that while she often sells books at workshops she conducts, her Couple Therapy graphic novel doesn’t sell well and attributed this to prejudices towards the comics form.

Pursey argued that the curated environment is a way to reach new audiences and this is an important part of the Sequential app (http://www.sequential.cc/) as, for some people, ‘comics shops and other mainstream comics platforms can seem like a closed world and they don’t know how to break into it’. Walsh stated that London-based comics books shop Gosh! is unlikely to offer a category as specialised as Graphic Medicine: ‘While we stock books on those subjects we would never bother to subdivide sections that thoroughly. It just creates more work than it creates sales.’

Rigby suggested that similar works are grouped together at Nottingham-based shop Page 45, but it’s not always a clear distinction where an individual book belongs: ‘Take something like Persepolis [Satrapi 2003] – would you put it in an autobiographical section, or would you put it in politics?’

2.2 Interactions with Academic and Health Institutions

At the time the interview took place, Williams was working in cooperation with Penn State University Press to produce a series of Graphic Medicine publications, including the first volume in the series, titled The Graphic Medicine Manifesto (Czerwiec et al 2015). Williams stated that editor-in-chief Boileau ‘is really keen to get it into the mainstream as well – not just into academic shops, to get it into normal bookshops and comic shops’. Publishing house Jonathan Cape does not directly market to academia to any great extent, although Bowler believed academics are still being reached: ‘what’s most effective is, you get the biggest noise you can on a launch through mainstream broadcast and print media, and that percolates.’

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.’

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 [Cantor 2014]. We have had quite a bit of interest from scientific and academic publishers around the world and Neurocomic is now available in around 10 languages…’

L.B. Lee stated that academic and professional interest in their work had been limited: ‘The only educational institution who’s had much interest in our work are zine libraries, who take an interest in radical mental health.’ They could see a potential method of their comics reaching more mental health professionals and academics but costs remained a barrier: ‘cons [conventions] and institutions are intended for doctors and people with money, not us. Some require academic certification, which we don’t have. The sheer cost of going has precluded us from going.’

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 higher-education 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.