Graphic medicine

1. Introduction

Version followed: the graphic medicine field as defined by Ian Williams (term coined 2007, GraphicMedicine.org) and set out in the Graphic Medicine Manifesto (Czerwiec, Williams, Squier, Green, Myers and Smith, Penn State University Press, 2015), with clinical and teaching practices taken from the Penn State College of Medicine comics elective (Michael J. Green) and the February 2018 AMA Journal of Ethics issue on graphic medicine. Psychotherapy adaptations are marked [synthesis].

Graphic medicine is not a therapy and not a manualised method. It is an interdisciplinary field and movement covering the use of comics in health care, medical education and patient care. Ian Williams, a Brighton physician and comics artist, coined the name in 2007 when he set up GraphicMedicine.org, and describes the field as the intersection between the medium of comics and the discourse of healthcare [source: Tufts University and University of South Dakota library guides, the latter quoting GraphicMedicine.org]. Its working material is the graphic pathography: a comic, usually non-fiction, about the experience of illness, written by patients to make sense of their illness, or by clinicians and trainees about care and training (term attributed to Green and Myers) [source: Yu 2018]. The field has its website, an annual international conference since 2010 (first held in London), and a Penn State University Press book series co-edited by Williams [source: CMAJ 2016 news feature on Williams]. The Manifesto is described by its publisher as establishing the field's principles and mapping it; its chapters cover comics scholarship, engaged scholarship, graphic novels in medical education, graphic pathography "in the classroom and the clinic", the iconography of illness, and MK Czerwiec's "The Crayon Revolution" [source: Penn State University Press page] [uncertain: the Manifesto's content is cited from the publisher's summary only].

How change is thought to happen: in the field's own accounts, reading illness comics lets clinicians and patients take in illness stories and infer what is implied between panels, which is compared to inferring what happens outside the clinic room; making comics helps patients and clinicians make sense of an illness or a care experience and give it meaning, and gives a relatively safe channel for experiences that are hard to say directly [source: Cole 2012, CMAJ; Monk 2018; Yu 2018]. For a psychotherapist, graphic medicine supplies (a) a reading resource for clients and families, (b) a reflective making practice for clients and for clinicians themselves, and (c) a set of ethical norms about depicting real illness and real people [synthesis].

Relation to comics-based therapy: structured comics-making exercises used as a therapeutic technique in their own right are covered in the companion guide on comics and graphic therapy (guide 030). This guide covers what is specific to graphic medicine: illness and care narratives, reading published graphic pathographies, clinician self-reflection, patient-education comics, and the safety, privacy and access rules of the field [synthesis].

2. Framework

There are no published phases, session counts or progression criteria for graphic medicine as a psychotherapy [uncertain: none in the cited sources]. Two structured formats are published. (1) Educational: the Penn State fourth-year elective "Graphic Storytelling and Medical Narratives" is a month-long seminar in which students read book-length graphic narratives (true and fictional) about patients and families living with illness, discuss them, do creative exercises to build drawing and writing skill and to prompt reflection, and each create a comic about a formative experience from training [source: Penn State news; Green 2013 abstract]. Monk's account of the same elective gives the sequence: read graphic pathographies; learn comic-making methods; brainstorm from one's own experience as a student and as a patient or relative; discuss ideas in the group; develop a full comic; use the finished comic as a discussion starter, with permission sought before wider publication [source: Monk 2018]. (2) Clinical reading group: a mental-health "Comic and Recovery Group" at Parc Sanitari Sant Joan de Déu (Barcelona area) ran three-month cycles for up to eight service users, linking five graphic novels to the stages of personal recovery and taking each book over two sessions (see 4.14) [source: Toribio Prieto & Boix, Som360].

The phases below adapt those two formats to individual and group psychotherapy. No published clinical phase scheme exists, so the phases, session counts and move-on criteria are the writer's synthesis [synthesis].

Phase A. Assessment and fit (part of 1 session). Goal: decide whether comics suit this client and this problem. Check reading ability, vision, attention, interest in comics, attitudes (some clients see comics as childish; the field itself notes comics were long stigmatised as low-brow [source: Olmsted and Green 2018]), current distress level and risk. Move on when the client consents and there is a clear use (understanding a diagnosis, feeling less alone, voicing a hard experience, carer support).
Phase B. Reading (1–4 sessions, with between-session reading). Goal: use a published graphic pathography or patient-education comic as a shared third object. Move on when the client can talk about what the comic shows and how it differs from their own experience. [synthesis] In the published recovery group, each book took two sessions: an introduction to the work and its themes, reading at home with a task to note elements of personal recovery, then a sharing session in which facilitators pointed to particular scenes [source: Toribio Prieto & Boix, Som360].
Phase C. Making (2–6 sessions, optional). Goal: the client draws or scripts their own illness or care story. Move on when there is a draft the client recognises as theirs, even if crude.
Phase D. Sharing decisions and closing (1 session or part of one). Goal: decide who, if anyone, sees the work, how it is stored, and what happens to it at the end of therapy; review what changed.

Format: individual, family or carer sessions, or closed groups (illness-specific support groups, staff reflective groups) [synthesis]. Sessions of 50–90 minutes suit making work; reading can be done between sessions [synthesis]. Clients can enter at Phase B or C, and many will use only Phase B [synthesis].

Professional frame: graphic medicine has no regulated profession, credential or registration of its own; it is practised by clinicians, educators, comics artists, librarians and scholars [source: Penn State University Press page; CMAJ 2016 feature] [uncertain: absence of a credential inferred from these sources]. A psychotherapist can use it within their existing registration and competence. If the work becomes art therapy (art-making used as the main therapeutic medium with interpretation of process and image), that requires art therapy training and registration, e.g. HCPC registration via a BAAT-recognised route in the UK, or AATA/ATCB credentials in the US [synthesis]. Public graphic medicine workshops run by comics artists are arts activities, not therapy; refer into them as you would any community arts offer and keep the therapeutic work in sessions [synthesis].

3. Guiding principles

Comics supplement conversation, never replace it. Use a comic or excerpt to open or clarify a point, then talk [source: Yu 2018].
Use parts, not wholes, when explaining. An excerpt that matches the client's question is often better than handing over a whole book [source: Yu 2018].
Comics show only some aspects of illness. Tell clients a published story is one person's experience, not a description of theirs [source: Yu 2018].
Images are open to more than one reasonable reading. Ask what the client sees; do not impose your interpretation [source: Yu 2018].
The gutter is where meaning is made. Invite the reader to fill in what happens between panels, and treat their filling-in as material [source: Cole 2012, reporting Green and Myers].
Dignity, compassion and respect in depiction. Illness images should be judged ethically as well as artistically [source: Olmsted and Green 2018, summarising Raphael and Rowell].
Accuracy and preference in patient education. Check the facts in any educational comic and respect a patient's preferred format; some do not want comics [source: Olmsted and Green 2018, summarising Ashwal and Thomas].
Make the patient's voice louder. Czerwiec's stated aim for comics in nursing education; in therapy, the client's own version of their story takes priority over the clinician's [source: Cole 2012; application [synthesis]].
Consent before collecting, no public disclosure of details. Patient and trainee comics are confidential clinical or educational material [source: Yu 2018].
Composite and simplified figures protect real people. Simple, generic art and fictionalised composites help keep the people depicted anonymous [source: Monk 2018].
Mind the hierarchy. Comics critical of a workplace or service can expose their makers; protect the maker from retaliation [source: Yu 2018].
Skill is not the point. Students with little drawing training make comics in the Penn State course; stick figures are acceptable [source: Penn State news, students create comics after skill-building exercises; stick-figure point [synthesis]].
Comic work is not diagnostic. Drawings may reveal a maker's concerns [source: Yu 2018], but no validated scoring exists in this field; never read a client's comic as evidence of abuse, disorder or risk on its own [synthesis].
Respect copyright. Lend, buy or borrow published comics; do not photocopy whole works for clients [synthesis].

4. Intervention inventory

The sources describe uses and teaching practices, not session scripts. Each entry says which parts are sourced and which are [synthesis]. All example language is illustrative. Published comics are named and described only; do not copy pages for clients.

4.1 Selecting a graphic pathography or health comic

Purpose / when: before any reading work, to match a published comic to the client's condition, age, culture, reading ability and current distress. Sourced: physicians may recommend specific comics to patients, and comics show only some aspects of illness [source: Yu 2018]. Selection steps are [synthesis].
Steps: (1) Name the job the comic must do: information, feeling less alone, a carer's view, a language for symptoms. (2) Draw on curated lists: GraphicMedicine.org, library graphic medicine collections, and the Manifesto's comics bibliography [source: Wikipedia, Graphic medicine; Penn State University Press page]. (3) Read the whole work yourself first, noting scenes of self-harm, suicide, abuse, medical procedures, death, sexual content and gore, and the page numbers. (4) Check facts in any educational comic against current guidance [source: Olmsted and Green 2018, summarising Ashwal and Thomas]. (5) Check access: print size, colour contrast, panel density, reading direction (manga reads right to left), language and translation, cost and library availability. (6) Offer two or three options and let the client choose; respect a refusal. Steps (1), (3), (5), (6) [synthesis].
Examples named in the sources (described, not reproduced): Living with a Black Dog: His Name Is Depression (Johnstone, 2006), a comic about depression; Binky Brown Meets the Holy Virgin Mary (Justin Green, 1972), an early autobiographical comic about compulsive neurosis; The Mysterious Symptoms: A Story about Type 2 Diabetes, following one character from symptoms to diagnosis and daily life [source: Yu 2018]; Nate Powell's Swallow Me Whole, a narrative of teenage mental illness used to show how variable illness experience is and to question whether diagnosis captures it [source: Penn State University Press page; Olmsted and Green 2018]; Menopause: A Comic Treatment, an anthology edited by MK Czerwiec [source: Wikipedia, Graphic medicine]. Content of other titles named only in lists (e.g. Our Cancer Year, The Tale of One Bad Rat, Epileptic, Stitches, Cancer Vixen) is not verified here [uncertain]; preview before recommending.
Example language (illustrative): "I've read this one through. It's one person's story of depression, and it has a hard section in the middle about not getting out of bed. Would you like to try it, or would something lighter suit you better right now?"
Watch for: a client who feels the comic trivialises their illness; a mismatch between the protagonist's outcome and the client's prognosis; recommending a work you have not read. Working: the client accepts, reads at least part, and brings a reaction.

4.2 Shared in-session reading of a graphic pathography

Purpose / when: when a client struggles to describe an experience directly, or when a shared third object lowers the intensity of talking about oneself. Sourced: comics give an accessible medium for patients and carers and help them make sense of illness [source: Cole 2012; Yu 2018]. Session procedure [synthesis].
Steps: (1) Agree a short extract (1–6 pages) in advance, avoiding flagged scenes unless chosen. (2) Read it together, the client holding the book or the screen; let them set the pace and stop at any time. (3) Ask open questions about what they notice first, then what fits and what does not fit their own experience. (4) Move from the character to the client only when the client does ("that's like me"). (5) Close with a lower-intensity question and a check of how they feel now.
Example language (illustrative): "What did you notice first on this page?" / "Which panel is closest to how it is for you, and which is furthest away?" / "Before we stop, where are you on a scale from settled to stirred up?"
Watch for: fixation on the character's fate as a prediction of the client's; flooding during procedure, hospital or self-harm scenes; using the comic to avoid talking about oneself for many sessions. Working: the client borrows words or images from the comic to describe their own state.

4.3 Reading the gutter (inference exercise)

Purpose / when: to bring out the client's assumptions and fears by asking what happens between panels. Sourced: Green and Myers argue that readers infer meaning from what is implied in the gutters, much as clinicians infer what happens outside the examination room [source: Cole 2012]. Clinical use with clients [synthesis].
Steps: (1) Choose two consecutive panels with a clear jump in time or place. (2) Ask the client what happened in between. (3) Ask what makes them think so. (4) Compare their filling-in with what the comic shows next. (5) Link the pattern to their life only if they make the link (e.g. always filling gaps with catastrophe).
Example language (illustrative): "Nothing is drawn between these two panels. What do you think happened there?" / "You filled that gap with bad news. Is that a habit of mind you recognise?"
Watch for: turning this into an interpretation test of the client; images being read in more than one reasonable way is expected [source: Yu 2018]. Working: the client notices their own inference style.

4.4 Excerpt for explaining a diagnosis, treatment or consent

Purpose / when: to support psychoeducation, a carer's understanding of a diagnosis, or a discussion of treatment preferences. Sourced: comics have been used to help family members understand doctors' explanations for informed consent (a 16-person study of relatives of patients with brain haemorrhage, most of whom found the comics useful); physicians should use parts of a comic to explain a diagnosis and elicit treatment preferences, use comics sparingly to clarify specific points, and arrange follow-up [source: Yu 2018].
Steps: (1) Pick the pages that answer one question. (2) Check the facts are current. (3) Show the excerpt, then ask the client to explain back what it says in their own words. (4) Correct misunderstandings. (5) Ask what the excerpt leaves out for them. (6) Note further questions for the next session or for the medical team. Steps (2)–(6) partly [synthesis].
Example language (illustrative): "This page shows how one family was told about the diagnosis. Can you tell me in your own words what the doctor in it is explaining?"
Watch for: stepping outside your scope on medical facts (refer questions to the treating team); a client who prefers text or speech [source: Olmsted and Green 2018, summarising Ashwal and Thomas]. Working: accurate explain-back and new questions.

4.5 Between-session reading for clients, families and carers

Purpose / when: for isolation, stigma, or a carer who needs to understand a relative's illness. Sourced: comics and graphic memoirs help patients, families and caregivers face illness [source: Wikipedia, Graphic medicine]; reader participation in making meaning can model collaboration among patients, clinicians and caregivers [source: Olmsted and Green 2018, summarising Gardner on Swallow Me Whole]. Procedure [synthesis].
Steps: (1) Agree an amount (a chapter, not the whole book). (2) Give a content note with the pages of hard scenes and permission to skip. (3) Suggest one marker: a sticky note on a page that felt true and one that felt wrong. (4) Agree what to do if the reading upsets them between sessions (stop, grounding plan, contact routes). (5) Start the next session from the marked pages.
Example language (illustrative): "Read as much as feels right, up to the end of chapter two. Put one note on a page that rang true and one that didn't. If pages 40 to 45 feel too much, skip them."
Watch for: non-reading (see 5.4); a carer using the book to tell the client how they should feel. Working: marked pages and a conversation that starts from them.

4.6 Client illness-narrative comic (making a graphic pathography)

Purpose / when: when a client wants to make sense of an illness, hospital stay or care experience and give it shape. Sourced: patients make comics to reflect on and give meaning to illness, e.g. a person who drew her psychosis and depression while on a psychiatric ward [source: Cole 2012; Yu 2018]. The making sequence is taken from the Penn State elective as Monk describes it: read examples, learn methods, brainstorm from experience, discuss, develop [source: Monk 2018]. Its therapeutic adaptation is [synthesis]. For specific panel-drawing exercises (e.g. structured panel prompts), use the companion comics and graphic therapy guide (030) rather than repeating them here.
Steps: (1) Show two or three published examples so the client sees that simple drawing is enough. (2) Teach minimal tools: panels, speech and thought balloons, captions, and the gap between panels. (3) Brainstorm moments, not the whole illness: list 5–10 moments and choose one that is meaningful but not the most traumatic. (4) Script in words or thumbnails first. (5) Draw in session with the therapist present, at the client's pace. (6) Talk about choices (what is shown, what is left in the gutter, how the self is drawn). (7) Stop each session with time to put the work away and settle (see 4.10).
Example language (illustrative): "You don't need to draw well. Stick figures and boxes work." / "Let's list some moments from the hospital stay and choose one you're ready to look at, not the hardest one yet." / "You drew yourself very small in this panel. What made you draw it that way?"
Watch for: choosing the worst moment first; perfectionism about drawing; making work in a hospital or ward that staff or other patients can see (agree storage). Working: the client can tell the story in sequence and describes some distance or new meaning.

4.7 Fictionalised or borrowed-frame comic for a distressing experience

Purpose / when: when direct depiction is too exposing, or the story involves real staff, family or colleagues. Sourced: Monk turned a real distressing observation of mistreatment into a fictional story in the frame of A Christmas Carol, with an unnamed attending and a character labelled only "med student"; simplified art helps preserve anonymity; the comic works as a safe method of expression for difficult topics [source: Monk 2018; Cole 2012].
Steps: (1) Offer a frame: a known story, a genre, an animal cast or a composite character. (2) Remove names, places, dates and distinctive features. (3) Merge several real people into composites. (4) Keep the emotional truth while changing facts. (5) Check together whether anyone could recognise themselves.
Example language (illustrative): "Would it be easier to tell this as if it happened to someone else, or in another kind of story?" / "If your manager saw this, could they tell it was them?"
Watch for: the real people still feeling present to the maker, which Monk notes [source: Monk 2018]; a fictional frame used to avoid feeling. Working: the client can say what happened and how it felt through the frame.

4.8 Clinician reflective comic (self-care, supervision, professional identity)

Purpose / when: for the therapist's own processing of difficult clinical experiences, burnout or moral distress, and for reflective practice groups. Sourced: Penn State students each make a comic about a formative experience in training, which supports reflection on professional identity [source: Penn State news]; MK Czerwiec drew her experiences as an HIV/AIDS hospice nurse and uses comics in nursing education [source: Wikipedia, Graphic medicine; Cole 2012]; trainees' comics can show how they see illness and what dissatisfies them in training [source: Yu 2018]. Use in a therapist's supervision is [synthesis].
Steps: (1) Choose an experience that still occupies you. (2) Thumbnail it in 4–8 panels. (3) Disguise the client completely (composite, changed age, sex, setting, diagnosis details) or leave the client out and draw only your inner side. (4) Bring it to supervision or a peer group as a discussion starter, not as a performance. (5) Keep it in your private records; do not post it online.
Example language (in a staff group, illustrative): "Bring a comic of one moment from work this month. Nobody needs to be recognisable, including you if you prefer."
Watch for: any detail that would let a client recognise themselves; using it in place of supervision. Working: new perspective on the experience, less rumination.

4.9 Group reading and discussion (support groups, staff groups, training)

Purpose / when: illness-specific support groups, carer groups, staff reflective groups, teaching. Sourced: book-length graphic narratives are read and discussed in seminar format, and student comics are discussed in the group [source: Penn State news; Monk 2018]; comics can show learners mistreatment in a safe, ethical manner [source: Monk 2018]. A published mental-health patient-group format is set out in 4.14; the steps below are a general version [synthesis].
Steps: (1) Agree group rules: confidentiality, the right to pass, no comments on others' drawing skill. (2) Give a content note for the extract. (3) Read silently or aloud. (4) Use rounds: one panel that stood out and why. (5) Open discussion. (6) Close with a grounding round.
Example language (illustrative): "Go round once: one panel that caught you, in a sentence. Passing is fine."
Watch for: one member's distress spreading through the group; comparison of prognoses; unsafe disclosures about named staff. Working: members connect their experiences without being flooded.

4.10 Pacing, closing and storing the work

Purpose / when: every reading or making session. [synthesis] throughout, informed by the sources' emphasis on safe expression and confidentiality [source: Monk 2018; Yu 2018].
Steps: (1) Agree a stop signal before starting. (2) Work in short blocks (10–20 minutes) with check-ins. (3) Stop making with at least 10 minutes left. (4) Physically close the book or turn over the page. (5) Move to the present: orientation, breath, a neutral topic. (6) Agree storage: client takes it, therapist keeps it in a secure folder, or it is destroyed; digital files follow your record-keeping rules. (7) At the end of therapy decide what happens to all the work.
Example language (illustrative): "Let's close the book here and put your pages face down. Look round the room and tell me three things you can see." / "Do you want to take this home, leave it with me, or tear it up?"
Watch for: leaving with unfinished, high-distress material and no plan. Working: the client leaves settled and knows where the work is.

4.11 Consent and de-identification before any sharing or publishing

Purpose / when: whenever a client's or a clinician's comic might be shown beyond the session (to family, a group, a training event, a website, a book). Sourced: get consent before collecting patient or trainee comics and do not disclose details publicly; protect makers from penalties in a hierarchy [source: Yu 2018]; present people as composites, use generic labels, share in a supervised group, and seek permission before wider publication [source: Monk 2018]. Checklist detail [synthesis].
Steps: (1) Default: the work stays in therapy. (2) If the client wants to share, separate written consent for each use (audience, format, duration, right to withdraw). (3) Remove identifiers of the client and of any third party, including staff, family and other patients, and check recognisability with the client. (4) Clinician-made comics about clients: no publication without the client's informed written consent, or full fictionalisation that the client could not recognise, checked against your professional body's confidentiality code. (5) Real named clinicians drawn critically: consider defamation and workplace risks before anything leaves the room. (6) Children: parental consent plus the child's assent, and remember the child may feel differently as an adult.
Example language (illustrative): "You can show this to anyone you like. If you want me to use it in teaching, I'd need your written permission, we'd remove anything that identifies you or anyone else, and you could change your mind later."
Watch for: pressure to share from family or services; clients wanting to publish while in crisis (suggest waiting). Working: clear, documented decision the client owns.

4.12 Patient-education comics in a service

Purpose / when: a service wants comics for psychoeducation (e.g. a diagnosis, a procedure, a therapy). Sourced: comics are used to raise awareness and help patients know what to expect; patient-education comics must be accurate, respect format preferences and be presented sensitively; evaluation methods are underdeveloped [source: Yu 2018; Olmsted and Green 2018]. Library collections are one access route [source: Wikipedia, Graphic medicine]. Development steps [synthesis].
Steps: (1) Involve service users in content and images. (2) Have content checked clinically. (3) Pilot with users of different literacy levels. (4) Offer text and audio alternatives. (5) Commission artists with clear licensing.
Watch for: stereotyped depictions of patients or staff; images that frighten rather than inform. Working: users can explain back the key points.

4.13 Physical materials and safety

Purpose / when: any making session. [synthesis]
Steps: use pencils, fine-liners, water-based markers and paper; avoid solvent markers in small unventilated rooms; keep craft knives and scalpels out of sessions with people at risk of self-harm, and count sharps in and out on inpatient units; offer digital drawing or collage (cut-out speech balloons, stickers, photo collage) for clients with limited hand function; templates of blank panels lower the barrier.
Watch for: ward rules on pens and sharps; latex or fragrance sensitivities with some materials.

4.14 Recovery-themed graphic novel group (two sessions per book)

Purpose / when: a closed group for adults using mental-health services (inpatient, day hospital, community or peer-led), to help members recognise elements of their own personal recovery, such as hope, resilience with support, and meaning and purpose, through characters in graphic novels. The published version ran three-month cycles of up to eight members, matched each of five graphic novels to a stage of the Andresen, Caputi and Oades recovery model (moratorium, awareness, preparation, rebuilding, growth), and reported better scores on a recovery-stage scale (STORI) without a controlled comparison. [source: Toribio Prieto & Boix, Parc Sanitari Sant Joan de Déu, Som360]
Steps: (1) Choose a short series of graphic novels and assign each to one recovery stage. (2) First session on a book: present the work and the themes it will be used to explore. (3) Between sessions: members read the book and note what they see as elements of personal recovery in it. (4) Second session on the book: members share their notes; the facilitators point to specific scenes to focus discussion and draw out the key elements. (5) Repeat for each book across the cycle, then give the recovery measure again. [source: Toribio Prieto & Boix, Som360; order of measurement and details of step (1) synthesis]
Example language (illustrative): "This book goes with the stage we called awareness. While you read it this week, mark any page where the character starts to see that things could change, and bring it next time."
Watch for: members comparing themselves unfavourably with a character further along; reading load for people with poor concentration (agree a chapter, not the whole book); content notes for scenes of self-harm, hospital admission or coercion. Working: members name hope, support or purpose in their own lives, not only in the character's. [synthesis]

5. Handling problems

The cited sources give little clinical problem-handling guidance. Unless a source is tagged, everything in this section is [synthesis].

Distress or overwhelm while reading. Graphic pathographies show procedures, psychosis, self-harm and death in vivid images, which can hit harder than text [synthesis]. Response: stop and close the book; ground in the present; name that the image affected them without asking for detail; next time choose a gentler extract or go back to text. Assess risk if the material touched on self-harm or suicide, following your standard risk-assessment and safety-planning practice.
Distress while making. A client drawing a traumatic hospital or ward experience may start re-experiencing it. Response: move from drawing the event to drawing the time after it, or to a safe place or a helper; switch to a borrowed frame (4.7); shorten blocks; return to stabilisation before more narrative work. Do not push exposure through comics unless you are trained in a trauma-focused method and the client has consented to that method; then follow that method's own pacing rules.
Ruptures over a recommended comic. A client may feel the chosen comic misrepresents their illness, is too bleak, or implies a prognosis. Response: own the choice ("I picked something that didn't fit you"), ask what was wrong with it, use the differences as material, and let the client choose next time. Comics show only some aspects of illness [source: Yu 2018].
"Comics are for kids." The field notes comics were long seen as juvenile or low-brow [source: Olmsted and Green 2018]. Response: say once that adult graphic memoirs about illness exist and have won literary awards, offer a short example, accept a no and use other means.
Stuck at the blank page / "I can't draw." Response: stick figures, words-only scripts in panel boxes, collage, or the therapist drawing to the client's instructions (the client stays the author). Students without drawing training make comics in the Penn State course after skill-building exercises [source: Penn State news].
Non-reading or non-making between sessions. Response: reduce the amount (one page), move reading into the session, check access barriers (cost, eyesight, dyslexia, concentration problems from depression or medication, no private space at home), and check whether the content was too painful.
Over-identification with a character. A client may take the protagonist's outcome as their own fate. Response: name the difference between that person's illness and theirs; consult the treating team about the client's own prognosis questions.
Using comics to avoid. Many sessions spent discussing a book without any link to the self. Response: name the pattern gently and ask what makes talking about themselves hard.
Clinician-made comics and privacy. Risk of a client recognising themselves in a therapist's published or online comic. Response: never publish client material without consent; fictionalise fully; remember that people depicted may still feel real to the maker [source: Monk 2018; Yu 2018].
Comics about staff or services. A client's or trainee's comic criticises named staff. Response: keep it in the room; discuss safer routes for complaints; protect the maker from retaliation within hierarchies [source: Yu 2018].
Over-reading the artwork. Treating a dark image as proof of abuse, psychosis or risk. Response: there is no validated scoring of illness comics; ask the client what the image means; base safeguarding and risk decisions on what the client says and on standard assessment, not on the drawing alone.
Children and young people. Response: check age ratings and content of published comics; involve parents or carers in choosing material with the young person's agreement; get parental consent and the child's assent for making and any sharing; follow safeguarding and mandatory-reporting duties if the work or talk discloses harm, explaining limits of confidentiality at the start.
Access. Barriers include low vision (offer large print, screen magnification, high-contrast digital editions), colour-vision differences, dyslexia and low literacy (comics may help, but dense lettering may not), unfamiliar reading direction, limited hand function (digital or collage), translation availability, and cost (use libraries; some libraries hold dedicated graphic medicine collections [source: Wikipedia, Graphic medicine]). Blind clients may prefer audio-described or text alternatives; comics are not suitable for everyone.
Cultural fit. Images of bodies, death, religious figures or mental illness can be unacceptable in some families or communities. Response: ask before showing; offer text-only options.
Copyright. Clients or services wanting copies of a published comic. Response: lend, buy or borrow; do not scan or photocopy whole works; ask publishers for permission for training use.
Scope. Medical questions raised by a comic go to the treating team; graphic medicine work supplements, never replaces, medical care or conversation [source: Yu 2018].

Sources

Sources:

Books and articles cited:

Czerwiec M.K., Williams I., Squier S.M., Green M.J., Myers K.R., Smith S.T. (2015). Graphic Medicine Manifesto. University Park: Penn State University Press.

Green M.J., Myers K.R. (2010), "Graphic medicine: use of comics in medical education and patient care", BMJ 340:c863, cited here as reported by Cole 2012 and Yu 2018 [uncertain: secondary].

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