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Metaphors of Mental Illness in
Graphic Medicine

This book investigates how graphic medicine enables sufferers of mental

illness to visualise the intricacies of their internal mindscape through visual
metaphors and reclaim their voice amidst stereotyped and prejudiced as-
sumptions of mental illness as a disease of deviance and violence.
In this context, by using Lakoff and Johnson’s conceptual metaphor the-
ory (CMT), this study uncovers the broad spectrum of the mentally ills’ ex-
periences, a relatively undertheorised area in medical humanities. The aim
is to demonstrate that mentally ill people are often represented as either
grotesquely exaggerated or overly romanticised across diverse media and
biomedical discourses. Further, they have been disparaged as emotionally
drained and unreasonable individuals, incapable of active social engage-
ments and against the healthy/sane society.
The study also aims to unsettle the sanity/insanity binary and its related
patterns of fixed categories of normal/abnormal, which depersonalise the
mentally ill by critically analysing seven graphic narratives on mental illness.

Sweetha Saji is Assistant Professor in the Department of English at Mount

Carmel College, Bengaluru. Her areas of research interest include Graphic
Medicine and Medical Humanities. She has published over ten research arti-
cles in SCI and Scopus indexed journals. She is an ad-hoc reviewer for Journal
of Graphic Novels and Comics and BMJ Journal of Medical Humanities.
She has presented over 12 research papers at International and National
conferences organized by prestigious institutions including the University of
Granada, Spain, JNU New Delhi, and IIT Madras.

Sathyaraj Venkatesan is Associate Professor of English in the Department

of Humanities and Social Sciences at the National Institute of Technology,
Trichy (India). He is the author of 6 books and over 90 research publications
that span African American literature, health humanities, graphic medicine,
film studies, and other literary and culture studies disciplines. He is most re-
cently the co-author of Infertility Comics and Graphic Medicine (2021) and
India Retold (2021).
Routledge Focus on Literature

Trump and Autobiography

Corporate Culture, Political Rhetoric, and Interpretation
Nicholas K. Mohlmann

Biofictions
Literary and Visual Imagination in the Age of Biotechnology
Lejla Kucukalic

Neurocognitive Interpretations of Australian Literature

Criticism in the Age of Neuroawareness
Jean-François Vernay

Mapping the Origins of Figurative Language in

Comparative Literature
Richard Trim

Metaphors of Mental Illness in Graphic Medicine

Sweetha Saji and Sathyaraj Venkatesan

Wanderers
Literature, Culture and the Open Road
David Brown Morris

Sham Ruins
A User's Guide
Brian Willems

For more information about this series, please visit: www.routledge.

com/Routledge-Focus-on-Literature/book-series/RFLT
Metaphors of Mental
Illness in Graphic Medicine

Sweetha Saji and

Sathyaraj Venkatesan
First published 2022
by Routledge
605 Third Avenue, New York, NY 10158
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2022 Sweetha Saji and Sathyaraj Venkatesan
The right of Sweetha Saji and Sathyaraj Venkatesan to be identified
as authors of this work has been asserted in accordance with sections
77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or
reproduced or utilised in any form or by any electronic, mechanical,
or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or
retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data
Names: Saji, Sweetha, author. | Venkatesan, Sathyaraj,
author.
Title: Metaphors of mental illness in graphic medicine /
Sweetha Saji, Sathyaraj Venkatesan.
Description: New York, NY : Routledge, 2022. |
Series: Routledge focus on literature | Includes
bibliographical references and index.
Identifiers: LCCN 2021032613
Subjects: LCSH: Mental illness—Treatment. | Visualization.
Classification: LCC RC475 .S25 2022 | DDC 616.891—dc23
LC record available at https://lccn.loc.gov/2021032613

ISBN: 9781032102092 (hbk)

ISBN: 9781032163505 (pbk)
ISBN: 9781003214229 (ebk)
DOI: 10.4324/9781003214229
Typeset in Times New Roman
by codeMantra
Contents

Acknowledgements ix

Introduction 1
Texts and Contexts 4
Overview of the Book 6

1 Drawing Illness: History, Theory, and the

Development of Graphic Medicine 9
Introduction 9
Early Comics and Healthcare 10
Narratives of Illness and the Birth of
Graphic Medicine 13
Preface to Graphic Medicine 14
Graphic Pathographies 16
Are Graphic Pathographies Education Comics? 18
Graphic Medicine as a Critique of Biomedicine 19
From Book Stalls to Classrooms 21
Trends in Graphic Medicine 23
Conclusion 25

2 Function of Metaphors in Illness Narratives 28

Introduction 28
A Brief Outline of Metaphor Theories 29
Comparison Theory 29
Transference Theory 29
Interaction Theory 31
Conceptual Metaphor Theory (CMT) 32
vi Contents
Metaphors and Contexts 33
Multimodal Metaphors and Illness Depiction 36
Why Metaphors? 40
Conclusion 42

3 Mental Illness and the Politics of Representation 46

Introduction 46
Defining Mental Illness 50
Mental Health Stigma and Medical Illustrations 55
Conjuring Stereotypes through Media
Representations 58
Conclusion 64
Acknowledgement 65

4 Nobody Memoirs as Counter-Discourse: Bipolar

Disorder and Its Metaphors 69
Introduction 69
Personal Stories, Memoirs, and Counter-Discourse 71
Metaphors as Counter-Diagnostic Figurations 76
Deconstructing Stereotypes 82
Conclusion 87
Acknowledgement 89

5 Visual Metaphors of OCD and Schizophrenia 93

Introduction 93
Perspectives in Context 93
Picturing the Psychicscape through Spatial
and Stylistic Metaphors 97
Traversing the Middle Ground through
Visual Metaphors 102
Conclusion 107
Acknowledgement 108
 Contents vii
6 Visualising the Fragmented Selves: Conventional and
Creative Metaphors of Depression 110
Introduction 110
Conventional and Creative Metaphors
of Depression 112
Stylistic Metaphors of Depression 119
Conclusion 122
Acknowledgement 123

Conclusion 126

Index 133
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Acknowledgements

I am grateful to Dr Sathyaraj Venkatesan, who has taught me the art

of academic writing and guided me throughout the course of four
years as a researcher. My gratitude also extends to my teachers of SB
College, Changanacherry, and BCM College, Kottayam, for inspir-
ing me to develop academic curiosity which led me to venture into
the novel interdisciplinary fields of medical humanities and graphic
medicine.
Immense thanks to Brick, Rachel Lindsay, Nate Powell, and Glyn
Dillon who spared their precious time in sending me images from
their memoirs. I fondly remember William Kuskin of the University of
Colorado Boulder and Andrea Wood of Winona State University for
their insightful comments and valuable suggestions on this book. I am
grateful to Matthew Noe of Harvard Medical School for his specific
comments on this book and also for the effort he takes to compile all
the resources related to this new field of graphic medicine and sharing
the same with the graphic medicine community online.
I am thankful to Jennifer Abbot, Mitchell Manners, and all the
editorial and production team members at Routledge, New York,
and Rajamalar of CodeMantra for their timely suggestions and help
during the various stages of the production of this book. I thankfully
remember the support given by the librarians at the American Corner;
Kottayam Public Library; Jawaharlal Nehru University, New Delhi;
Indian Institute of Technology, Madras; and National Institute of
Technology, Trichy.
My sincere gratitude and respect to my parents and siblings for their
encouragement and prayers. My heartfelt love and thanks to my hus-
band, Gijo John George, for his unconditional support. Special thanks
to S. Pushpanathan, Rajima, Ninu, and Geerthy for their unflinching
friendship and love.
x Acknowledgements
I thank the publishers of Routledge, Sage, Rupkatha, and Media
Watch, for permitting me to use earlier versions of some of the chap-
ters in this book which were published as “Drawing the Mind: Aes-
thetics of Representing Mental Illness in Select Graphic Memoirs” in
Health: An International Journal for Social Study of Health, Illness and
Medicine, Sage vol. 25, no.1 (2021); “Capturing Alternate Realities:
Visual Metaphors and Patient Perspectives in Graphic Narratives on
Mental Illness” in Journal of Graphic Novels and Comics (2020); “Re-
flections on the Visceral: Metaphors and Illness Experience” in Rup-
katha Journal on Interdisciplinary Studies in Humanities vol.12, no.1
(2020); “Graphic Illness Memoirs as Counter-Discourse” in Journal of
Graphic Novels and Comics (2019); and “Conjuring the ‘Insane’: Rep-
resentations of Mental Illness in Medical and Popular Discourses” in
Media Watch vol.10, no.3 (2019).
This book is dedicated to my family and all my teachers who
moulded me through these years. They seeded in me empathy, the
foundation on which this book is thought about and made.

Sweetha Saji

My special debt of gratitude to Professor Gurumurthy Neelakantan,

Indian Institute of Technology, Kanpur, for teaching me the art of
interpretation and academic writing. I would like to thank Jennifer
Abbott and Mitchell Manners for their utmost professionalism and
enthusiasm during the preparation of the manuscript. My deep sense
of gratitude to the International Graphic Medicine collective for their
extraordinary support: Dr Ian Williams (founder of Graphic Medi-
cine), MK Czerwiec (co-founder of Graphic Medicine), Susan Merrill
Squier, Dr Michael Green (Penn State College of Medicine), Matthew
Noe (Harvard Medical School), A David Lewis (Massachusetts Col-
lege of Pharmacy and Health Sciences), Dr Brian Callender (Uni-
versity of Chicago), and Larry Churchill (University of Vanderbilt).
Thanks to the reviewers for their thoughtful critiques and valuable
suggestions. Thanks to William Kuskin (University of Colorado,
Boulder) for being a great source of motivation. Special thanks are due
to the faculty of the Department of Humanities and Social Sciences,
National Institute of Technology (NIT), Tiruchirappalli. Thanks also
to the publishers who allowed to reproduce essays contained in this
book. Dedicated to my wife, Pavithra Ayyapan, and my son, Taran
Sathyaraj.

Sathyaraj Venkatesan
Introduction

The pivotal role of humanities in medicine has been recognised in the

1940s as it aimed at reuniting technical and humanistic theory and
practice. Since then, discussions on the interdisciplinary field of health
humanities promoted the inculcation of humane values and concerns
within medical practice by exposing students of medicine to litera-
ture, culture, philosophy, and the arts. Steering away from symptom-
based approaches, health humanities foreground patient-centred care
that takes into account varied socio-cultural factors that modulate
and determine one’s experience of illness. Moreover, the field shies
away from privileging singular perspectives and grants voice to the
care provider as well as to the patient. Broadening the scope of this
field, later developments in health humanities like narrative medicine
among others explore questions of empathy, narrative humility, and
ethics of representation. Taking cues from these historical milestones,
the field of graphic medicine, which explores representations of illness
experiences in the medium of comics, “resists the notion of the univer-
sal patient and vividly represents multiple subjects with valid and, at
times, conflicting points of view and experiences” (Czerwiec et al. 2).
Within this framework, the experience of mental illness becomes sig-
nificant as it is often misrepresented in various verbal, visual, and me-
dia cultures. Such representations promote stereotypes and affect the
very social and personal well-being of the mentally ill. In this context,
personal narratives of mental illness experience grant agency to such
marginal lives and thus provide an alternate perspective to the current
(toxic) discourses on mental illness.
As such, the COVID-19 pandemic has reanimated several issues
about mental health and well-being. Quarantine, isolation, and social
distancing which are the recommended measures to limit the spread
of the viral disease have not only resulted in socio-cultural and eco-
nomic crisis but also have led to personal disruption and extreme

DOI: 10.4324/9781003214229-1
2 Introduction
mental health issues. As a response, health professionals discuss the
importance of attending to the needs of the mentally ill and being sen-
sitive to those who suffer mental health issues during the pandemic.
Artists and writers, on the other hand, have creatively engaged in such
invisible dimensions of one’s life and also have elicited (empathetic)
responses via print and social media. Such emerging trends not only
extend ingress into the subjective dimensions of patient experience but
also bring under scrutiny the extant medical practices and popular
representations of madness that underrepresent or over romanticise
the experience of mental illness. Graphic memoirs on mental illness, in
particular, find expression through the unique semiotic nature of com-
ics, which facilitates the encapsulation of complex psychic landscapes
and embodiment of the artist’s experiences. Such representations of
psychological experiences that concern with challenging prevailing
normativities necessitate a creative use of means of expression. In so
doing, these verbo-visual techniques such as the use of visual meta-
phors provide vividness and easily digested expression, translating
the sufferer’s altered mental perspective effectively for the reader. The
deployment of such elements inherent in the medium facilitates multi-
layered connections to the patient narrative which provide a depth be-
yond the raw medical discourse, and thereby reconfigures the extant
perceptions surrounding mental illness.
An analysis of diverse verbal and visual representations of mental
illness in contemporary media and medical discourses reveals a persis-
tent gap between standardised and stereotyped perspectives about the
mentally ill and the subjective realisation of them. Several literary and
cultural critics have commented on this glaring lacunae and its negative
repercussions on the personal, familial, and social life of the mentally
ill. Sander Gilman’s Seeing the Insane (1982), Simon Cross’ Mediat-
ing Madness: Mental Distress and Cultural Representation (2010), and
Elizabeth J. Donaldson’s Literatures of Madness: Disability Studies
and Mental Health (2018) are some of the seminal critical readings on
representations of the mentally ill across media and its unconstruc-
tive effects. While these texts explore the politics of representation and
its repercussions in the lives of the mentally ill, a critical reading of
personal narratives of mental illness which are drafted using verbal
and visual modes unravels the unvoiced socio-cultural and personal
dimensions of living with mental illness from significant marginal per-
spectives. As such, a nuanced understanding of the affordances of the
comics medium and the metaphorical patterns which recur in these
graphic narratives enables a comprehensive reading experience which
generates a community of sufferers on the one hand and facilitates
critical responses on health and illness on the other hand.
 Introduction 3
Although concepts and theories on metaphors date back to Aris-
totle, current research on metaphors, particularly visual metaphors,
draws strength from George Lakoff and Mark Johnson’s conceptual
metaphor theory (CMT) which deems metaphors to be “pervasive
in everyday life, not just in language but in thought and action” (3).
Lakoff and Johnson and other theorists like Charles Forceville and
Elizabeth El Refaie primarily focus on the cognitive mapping between
two different conceptual categories that evoke metaphorical meanings
that arise “from the continuous interplay of social and cultural con-
straints, neural processing, and the unfolding of in-the-moment sen-
sorimotor experience” (El Refaie 4). These meanings that emerge out
of such conceptual mappings actualise otherwise abstract feelings and
emotions that require a visual language that transcends literal expres-
sions. In the context of mental illness, the author/artist resorts to met-
aphors which effectively encapsulate their complex psychic landscapes
which seldom find expression in literal language due to the absence of
physical/visible signs of illness. Although Lakoff and Johnson’s CMT
is extended to visual narratives to investigate “the correspondence
between the visual form and meaning” (Cohn 68), artists also deploy
metonymic relationships between images and “unseen events” (Cohn
80). In other words, when graphic narratives use metaphor, it is usually
through another aspect of metonymy—polysemy—in which some-
thing is figured in multiple ways, through visualisation and through
text. As such, in a visual medium like comics, artists use panels to
“show something related to an event, without showing the event itself”
(Cohn 80). These ‘unseen events’ correspond to what Ian Williams
defines as the ‘invisible’ iconography used in depicting psychological
conditions (Czerwiec et al. 119).
Under the rubrics of the iconography of illness in the medium of
comics, Williams classifies illness representation into ‘the manifest,’
‘the concealed,’ and ‘the invisible.’ ‘The manifest’ implies the depiction
of illness or scars of treatment “as ‘realistically’ as possible” (Czer-
wiec et al. 121). Drawing specific attention to David Small’s memoir,
Stitches, Williams enunciates the usefulness of ‘manifest’ images in
rendering physical/bodily scars. Such graphic depiction which con-
verges sickness with grotesqueness consequently evokes disgust/pity in
the reader. When illness conditions are vaguely manifest as in the case
of psychosomatic disorders, Williams christens it as ‘the concealed.’
In such cases, Williams remarks that they “may not be noticed by, or
are hidden from, the casual observer” (Czerwiec et al. 119). In the third
category of illness depiction called ‘the invisible,’ the comic artist re-
sorts to the “iconographic flexibility of the form” (Czerwiec et al. 119)
for the veracious articulation of the visceral and analytic dimensions
4 Introduction
of psychological suffering. Exploiting the flexibility of the comics me-
dium, the artists choose/create idiosyncratic icons and experiment
with visual tropes creating new visual patterns and an internal vocab-
ulary of images to align with their peculiarity of experience. Several
mental illness graphic narratives such as Ellen Forney’s Marbles, Allie
Brosh’s Hyperbole and a Half, Darryl Cunningham’s Psychiatric Tales,
Elaine Will’s Look Straight Ahead, and Steven Struble’s Li’l Depressed
Boy, among others, exploit the iconographic flexibility of the comics
medium in order to concretise and effectively relate their mental states
through visual metaphors.

Texts and Contexts

This book critically analyses seven graphic narratives on men-
tal illness, namely, Nate Powell’s Swallow Me Whole (2008), Brick’s
Depresso (2010), Darryl Cunnigham’s Psychiatric Tales (2011), Ellen
Forney’s Marbles (2012), Glyn Dillon’s The Nao of Brown (2012), Allie
Brosh’s Hyperbole and a Half (2013), and Rachel Lindsay’s Rx (2018).
These narratives include both fictional and non-fictional accounts
that deal with mental illnesses including bipolar disorder, depres-
sion, schizophrenia, and obsessive compulsive disorder (OCD). The
primary texts were selected on the basis of their delineation of expe-
riential dimension of the sufferer’s life, and their use of comics as a me-
dium of expression in exploring cultural and emotional aspects of the
illness through different kinds of metaphors that convey their unique
emotional landscapes. The authors comprise established comic artists
and blog writers who suffer(ed) from various forms of mental illness.
The study also aims to inspire qualitative and quantitative research
on how factors such as gender, ethnicity, and race influence and deter-
mine (mental) illness conditions.
First, we follow a phenomenological approach which aims to cap-
ture the lived realities of those who suffer from mental illness. This
approach respects the perspective of those affected by the illness
condition by being aware of the personal, socio-cultural, and para-
digmatic discourses that shape the way reality is perceived by them.
Second, the core chapters specifically follow certain tenets of post-
structuralism that problematise social and medical discourses on
mental illness that mediate the way in which the illness condition and
sufferers of the same are perceived. Accordingly, the binaries that
underpin negative attitudes towards mental illness are deconstructed
through concepts like counter-space and counter-diagnosis. Analysis
of visual and verbo-visual metaphors in the graphic memoirs which
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