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 Small, personal videogames about mental health
An informal survey of Bitsy games
Mikhail Fiadotau
fiadotau@tlu.ee
School of Digital Technologies, Tallinn University
Tallinn, Estonia
ABSTRACT
The article introduces an ongoing research project dedicated to
short, personal videogames about mental health made using Bitsy:
a tiny, browser-based game creation tool. It introduces preliminary
observations from a survey of such games on the game distribution
platform Itch.io. The article outlines the themes the games address
and how they communicate their authors’ personal experiences
and intended messages. It also discusses the significance of such
games in the landscape of today’s gaming.
CCS CONCEPTS
• Social and professional topics → People with disabilities; • Ap-
plied computing → Media arts; Computer games.
KEYWORDS
game creation, mental health, participatory culture, platform studies
ACM Reference Format:
Mikhail Fiadotau. 2022. Small, personal videogames about mental health:
An informal survey of Bitsy games. In FDG ’22: Proceedings of the 17th
International Conference on the Foundations of Digital Games (FDG ’22),
September 5–8, 2022, Athens, Greece. ACM, New York, NY, USA, 4 pages.
https://doi.org/10.1145/3555858.3555917
1 INTRODUCTION
This short article introduces an ongoing research project dedicated
to exploring small, personal videogames by non-professional cre-
ators that reflect on mental health issues. Specifically, the focus is
on games made with Bitsy: a tiny browser-based game creation tool
that has gained popularity in recent years as an approachable entry
point into game making for creators with limited technical knowl-
edge and/or time. By lowering the entry barrier to game creation
and the time commitment required to make one, Bitsy (together
with other tools such as Twine) has helped diversify the range of
voices, topics, and perspectives that videogames can address. These
include topics that mainstream commercial videogames have either
largely neglected to address, or have addressed in stereotypical and
potentially harmful ways—such as mental well-being and mental
ill-health.
Permission to make digital or hard copies of all or part of this work for personal or
classroom use is granted without fee provided that copies are not made or distributed
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on the first page. Copyrights for components of this work owned by others than the
author(s) must be honored. Abstracting with credit is permitted. To copy otherwise, or
republish, to post on servers or to redistribute to lists, requires prior specific permission
and/or a fee. Request permissions from permissions@acm.org.
FDG ’22, September 5–8, 2022, Athens, Greece
© 2022 Copyright held by the owner/author(s). Publication rights licensed to ACM.
ACM ISBN 978-1-4503-9795-7/22/09. . . $15.00
https://doi.org/10.1145/3555858.3555917
The exploratory study outlined in this article covers Bitsy games
about mental health distributed on the popular website Itch.io. The
goal of the study is to map the specific themes the games address,
as well as analyze how they choose to address them in terms of
gameplay, writing, and audiovisual content. This article presents
observations from an initial survey of mental health-themed games
on Itch.io, as well as discusses future directions for the project.
2 BACKGROUND
2.1 Videogames and mental (ill-)health
Mental ill-health has often been stigmatized in society, and its
depictions in popular media have continually reinforced the stigma.
This has been evident in videogames, especially in the horror genre,
where mental asylums are often used as settings and villains are
habitually depicted as being clinically insane [7]. By perpetuating
the stereotype of mental ill-heath as inevitably resulting in violent
and dangerous behavior, popular media exacerbate the challenges
faced by people struggling with their mental health in real life [14].
This status quo is especially problematic considering how many
people globally are affected by mental health issues. For example,
anxiety disorders alone are estimated to affect some 5% of adults
globally, while up to 7% of the world’s adult population experience
depression [18] (these numbers are likely to have increased during
the COVID-19 pandemic). Less prevalent, but relatively common
mental health issues include bipolar disorder, schizophrenia, eating
disorders, self-harm, body dysmorphic disorder, and others. Contro-
versially, neurodevelopmental conditions such as autism spectrum
disorders (ASD) and attention deficit hyperactivity disorder (ADHD)
are also sometimes characterized as mental illnesses—a label dis-
puted by the neurodiversity community, which holds that these
conditions should be understood as natural variations in brain func-
tion [16]. Regardless of whether they are themselves considered
disorders, conditions such as ASD and ADHD are often accompa-
nied by mental health comorbidities such as anxiety and depression
[5].
The vast majority of the people experiencing mental ill-health
can both function in society and contribute to it, as well as get better
with proper treatment and social support. Yet, the stigma associ-
ated with mental ill-health makes many of these people reluctant
to seek diagnosis, disclose their condition to others, and request
work accommodations, thus negatively affecting their well-being.
While videogames, like other popular media, have been complicit
in reinforcing this stigma, they can also help challenge it [3, 14].
In recent years, gaming has seen an increase in more nuanced and
realistic depictions of mental health. From AAA titles such as Hell-
blade to indie hits such as Celeste, some videogames have sought
to change the conversation around mental ill-health and reduce
FDG ’22, September 5–8, 2022, Athens, Greece
the stigma associated with it by portraying relatable, emotionally
complex protagonists struggling with mental health [3, 15].
Another promising trend has to do with the increased avail-
ability of game creation tools, distribution platforms, and maker
communities to non-professional creators with limited technical
skills. This reflects games’ place in the broader shift toward par-
ticipatory culture—a mode of cultural production characterized by
“relatively low barriers to artistic expression and civic engagement,
strong support for creating and sharing creations, and some type of
informal mentorship whereby experienced participants pass along
knowledge to novices” [11]. Thanks to this, individual creators have
been able to share their own, often highly personal, stories and
experiences via the medium of games, touching on issues often
overlooked or represented stereotypically in the commercial game
industry. This has included issues relating to mental health, with
game jams dedicated to mental health receiving attention both for
empowering creators to reflect on and share their lived experience,
and for their broader awareness-raising potential [3].
In this context, understanding the tools used by creators is key to
understanding their games. This is because, as research in platform
studies has demonstrated, hardware and software platforms (e.g.,
game engines) function as creative and technological constraint,
simultaneously limiting and empowering creators and affecting
their design choices [2]. Contextualizing a game within the tool
used to make it can thus be akin to investigating a painter’s use of
materials and tools in order to analyze their painting. This is why I
decided to focus on games made with one tool: Bitsy.
2.2 Bitsy: a tool for radical game design
Bitsy1 by Adam Le Doux is a browser-based tool designed to create
small, simple games that consist of moving on a two-dimensional
grid and interacting with objects, which can be accompanied by
text descriptions. Each level in a Bitsy game is a 16x16 grid of
8x8 pixel sprites. Each sprite can only contain two colors and one
or two frames of animation, and represent a character, an object
that can be interacted with or collected, a non-interactive back-
ground image, or an impassable wall. Visually, Bitsy creations evoke
early videogames, except they look more pixelated and minimalist
than most of the actual retro games that they visually reference.
Gameplay-wise, Bitsy games tend to be what is known as “walking
simulators,” involving the playable character exploring the envi-
ronment, talking to its inhabitants, and interacting with objects in
order to advance to the next level or unlock an ending.
Thanks to its simplicity, Bitsy can be used by creators with no
game development experience and requires no programming knowl-
edge. The resulting games are small, self-contained HTML files that
can be played in any modern browser (including on mobile devices)
and are easy to self-host or publish on a game distribution platform
such as Itch.io. In this regard, Bitsy is similar to Twine—another
browser-based game engine popular with independent creators
looking to experiment with the medium [9]—but represents the
game world visually rather than as passages of clickable text.
As of the time of writing, Bitsy was the sixth most widely game
engine on Itch.io2 ahead of such tools as Unreal Engine and RPG
1 https://ledoux.itch.io/bitsy
2 https://itch.io/game-development/engines/most-projects
Fiadotau
Maker, both of which have received significantly more coverage
in popular and academic discourse alike. What makes Bitsy so em-
powering for creators is not just the technical simplicity of using
it, but its emphasis on creative constraint. The tool was deliber-
ately designed to dramatically limit what the creator can do. By
eliminating most features found in traditional game engines such
as Unity and thereby limiting creators’ choice of genre, game me-
chanics, and visual style, Bitsy makes it easier to finish a game; but
it also promotes creativity, encouraging game makers to use the
seemingly basic features in ingenious ways [17]. (Due to Bitsy’s
open-source nature, many community-developed "hacks" are also
available that extend or alter the tool’s functionality, from enabling
binary dialogue choices to rendering the game level in quasi-3D.)
Additionally, Bitsy’s design is geared toward creating games that
are approachable and accessible to players. This is because Bitsy
is designed to produce short, browser-playable games that do not
require advanced gaming skills nor contain many challenges. As
such, Bitsy experiences are accessible to people who normally have
little time to play videogames, or lack the hardware for modern
games, or are not confident players.
These features make Bitsy perfectly suited for radical game de-
sign: creating games that “challenge the accepted norms embedded
in the gaming industry” [8], from tackling political issues to artistic
experimentation [10]. It is no surprise that Bitsy has also been used
to create small, personal interactive stories about mental health.
3 INITIAL SURVEY
3.1 Selection and mental health themes
As Bitsy itself is mainly distributed via the popular gaming platform
Itch.io, and since I had already encountered several mental health-
themed Bitsy games on the same platform, I opted for Itch.io as the
starting site for my initial exploratory survey. The survey includes
games distributed on Itch.io that their creators tagged with both
“made-with-Bitsy” and “mental-health.” Altogether, as of the time
of writing, the search results for the two tags combined returned
33 games. It is likely that there are other games on Itch.io that have
been made using Bitsy and address mental health, but that have not
been tagged by their creators as such; it is also highly probable that
other Bitsy games on the subject can be found on other platforms,
social media, etc. As such, this initial selection of 33 games is far
from comprehensive.
Of the 33 games, 31 are in English, one is in French, and one is in
Spanish. The initial account below focuses on the English-language
games only.
I played the 31 games either in full (most took no longer than 5
minutes to complete) or until I got stuck: two of the games proved
impossible for me to finish, either because of a technical issue or
because I could not understand how to progress beyond a certain
point. After playing the games, I tagged them based on the specific
mental health issue (or, in some cases, multiple issues) they address.
Oftentimes, the issues were expressly stated in the game’s descrip-
tion on the Itch.io; in other cases, they were mentioned inside the
game itself. On several occasions, there was no explicit mention
of the mental health condition addressed by the game, but it could
be easily inferred. For example, You Are on the Bus3 depicts its
3 https://royalpan.itch.io/you-are-on-the-bus
Small, personal videogames about mental health
Table 1: Frequency of Mental Health Conditions in Selected
Games
Mental health condition Frequency
Anxiety 6
Depression 5
Loneliness 4
Suicidal ideation 4
ADHD 3
Autism 3
Grief 3
Self-harm 2
Trauma 2
OCD 1
Substance abuse 1
Unspecified 6
protagonist experiencing a shutdown: an episode of disorientation
and unresponsiveness to the outside world triggered by sensory
overload or a breakdown in established routine [1]. Shutdowns are
associated with ASD, so even though the game does not expressly
state that its protagonist is on the autism spectrum, its depiction of
a shutdown and the use of the term “shutdown” itself provided me
with enough information to tag it with “autism.”
For some of the games, I could not identify what mental health
condition they depicted, in which case I tagged them as “unspeci-
fied.” For example, dont look at the sun4 reflects on the dehumanizing
experience of a patient in a psychiatric ward, but does not mention
the diagnosis that got the protagonist there in the first place.
The range of issues tackled by games in my selection is presented
in Table 1. Not all of these are specific medical diagnoses; instead,
some are issues recognized by the game authors as being related to
mental health and well-being, such as loneliness. For the purposes of
this study, it was more important for me to present the authors’ own
perspective on what constitutes mental health issues than to adhere
to an established mental disorder taxonomy such as DSM-5 (The
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,
a taxonomy developed by the American Psychiatric Association
and widely used in psychiatric practice).
Anxiety and depression are the most commonly tackled issues,
mirroring their real-life prevalence, followed by the themes of lone-
liness and suicidal ideation. Among neurodevelopmental conditions,
both ADHD and autism are represented in three games; one other
game deals with obsessive-compulsive disorder (OCD). Another
game tackles, among other things, substance abuse.
3.2 Game content and expressive techniques
In terms of content, most of the games seek to replicate (with various
levels of commitment to realism) their authors’ real-life experiences:
from coping with loneliness and isolation by befriending a group of
crows in one for sorrow, two for joy5 to an autistic person’s struggling
4 https://vividgrim.itch.io/dont-look-at-the-sun
5 https://erika-hg.itch.io/one-for-sorrow-two-for-joy
FDG ’22, September 5–8, 2022, Athens, Greece
to follow social norms such as small talk while experiencing a near-
shutdown in How are you doing?6 . Some of the games take a more
figurative approach to representing lived experience. In The Trash
Collector7 , for example, the protagonist spends most of their days
collecting trash left behind by other people; and when they return
home, exhausted, in the evening, the place is full of their own,
uncollected trash that they do not have the energy to deal with and
no one else will help them with. This can be read as a metaphor for
compassion fatigue: emotional strain associated with, among other
things, helping other people deal with their emotional baggage at
the expense of your own self-care [6].
While most of the games in the selection are what Loh et al. [12]
describe as message broadcasters (i.e., games mainly designed to
raise awareness about an issue), four could be classified as serious
games in that they seek to promote positive thinking and teach
coping skills. Psst... I have a secret8 accomplishes this by breaking
the fourth wall and taking the form of the game’s author speaking
directly to the player, sharing her struggles with social anxiety and
low self-esteem, as well giving both herself and the player encour-
agement. Anxious Avoidance Is Not Fun9 illustrates that avoiding an
anxiety-inducing task is often counterproductive, especially when
the task is ultimately inevitable, by having the player choose be-
tween a straightforward route and a long, mazy route that still leads
to the same destination.
It is interesting to note that, while Bitsy is ostensibly a very lim-
ited engine in terms of functionality, the games in my selection use a
wide range of techniques to communicate their authors’ experience
and provoke specific emotional and intellectual responses in the
player. In i hurt myself10 , non-player characters’ dialogue becomes
increasingly garbled as the protagonist is unable to concentrate
on the words of those around them, which the game represents
by replacing an increasing number of letters in words with special
characters such as *, $, and #, until the text becomes completely
unreadable. The game also visually represents the protagonist as
a moving sandstorm or cloud, which is in stark contrast to the
anthropomorphic non-player character—this helps communicate
the protagonist’s alienation, inner instability, and the feeling of
“being a mess.”
THERE AREN’T REALLY WORDS. . . 11 first familiarizes the player
with the level layout (a rental apartment shared by several room-
mates), then changes the layout beyond recognition and adds glitches
to represent the disorientation experienced by the protagonist after
they learn of a friend’s suicide.
dice.12 has the player roll a die to choose what kind of life their
character will live. Yet, despite the different starting circumstances,
each roll of the die eventually results in the protagonist experienc-
ing an existential crisis: even though the protagonist has apparently
learned from the mistakes of their previous lives, they still cannot
fix themselves.
6 https://transrightsrose.itch.io/how-are-you-doing
7 https://azuladev.itch.io/the-trash-collector
8 https://ninfa.itch.io/secret
9 https://kooky.itch.io/anxious-avoidance-is-not-fun
10 https://pastellexists.itch.io/i-hurt-myself-postjam
11 https://rosekiid.itch.io/there-arent-really-words
12 https://nen-kaii.itch.io/dice
 FDG ’22, September 5–8, 2022, Athens, Greece
How are you doing?13 uses audio, including recorded dialogue, as
well as sudden changes in level design to communicate the stress
and disorientation experienced by a person on the autism spectrum
when going through a shutdown and still having to conform to so-
cial expectations. In the game, small talk initiated by acquaintances
transports the player from their immediate physical environment
to lonely places inside their mind consisting entirely of letters B, A,
and D—“BAD” being the honest, but socially unacceptable response
to the seemingly innocent, casual question “How are you doing?”
Many of the games’ authors appear to be aware and reflective
of the artistic dimension of their work. Some games use carefully
crafted color palettes and visual metaphors (envy and equanim-
ity14 ), while others emphasize evocative writing and are effectively
interactive poems (i don’t like it when the ocean barks at me15 ).
This indicates that, to some creators at least, communicating their
lived experience is closely intertwined with artistic expression.
This speaks to both the therapeutic aspect of art and its capacity
for communicating information in an evocative way. This artistic
dimension warrants deeper study in the future.
4 FUTURE DIRECTIONS
Examples above demonstrate how small independently-made
videogames can address themes relating to mental health from
personal, experiential perspectives, providing a counterbalance to
the negative stereotyping still prevalent in mainstream gaming.
Coupled with the emergence of game jams and events dedicated to
mental health and gaming [4], this can help raise awareness and
change popular discourse around the issue.
By tackling mental health themes, these games can be therapeu-
tic for their creators (which Psst... I have a secret acknowledges by
thanking the player for "listening" at the end of the game). Many
of them can also be therapeutic for players who themselves expe-
rience mental ill-health, thanks to the games’ creating a sense of
relatedness and sharing positive messages and coping mechanisms.
Bitsy itself can be seen as, in Nicoll’s terms, a minor platform [13]:
one that is rarely acknowledged in "official" game historiographies,
which tend to focus on mainstream gaming, but that has exerted
an impact on how we use and think about games.
The account above is both highly selective and largely descrip-
tive, briefly citing specific features in individual games in an effort
to outline the range and scope of themes and expressive techniques
found in mental health-themed games made with Bitsy. This rep-
resents an early stage in an ongoing project whose ultimate am-
bition is to map these games’ content in a more comprehensive
and structured way. Doing so could include developing a consistent
tagging scheme for games’ expressive elements, as well as classify
them according to their goals (e.g., self-therapy, awareness-raising,
promoting positive thinking, teaching coping mechanisms, etc.)
Additionally, the analysis could be expanded beyond the games’
content to their description on the website and comments left by
players. Another promising direction, from a platform studies per-
spective, would be to compare games about mental health made
13 https://transrightsrose.itch.io/how-are-you-doing
14 https://miniwoolf.itch.io/envy-and-equanimity
15 https://dino-de-haas.itch.io/i-dont-like-it-when-the-ocean-barks-at-me
View publication stats
Fiadotau
with Bitsy and those made with other tools, in order to under-
stand how different platforms’ affordances influence the games’
expression.
REFERENCES
[1] Luke Beardon. 2017. Autism and Asperger Syndrome in Adults. Sheldon Press,
London.
[2] Ian Bogost and Nick Montfort. 2008. New media as material constraint: An
introduction to platform studies. In Electronic techtonics: Thinking at the interface.
Proceedings of the First International HASTAC Conference, Erin Ennis, Zoë Marie
Jones, Paolo Mangiafico, Mark Olson, Jennifer Rhee, Mitali Routh, Jonathan E.
Tarr, and Brett Walters (Eds.). Lulu Press, Morrisville, NC, 176–193. https:
//hdl.handle.net/10161/9139
[3] Hsiao-Wei Chen. 2021. Mental Jam: Video game co-creation for young people
with lived experiences of depression and anxiety. Games for Change Asia-Pacific
Journal 1, 2021 (2021), 177–203.
[4] Hsiao-Wei Chen, Jonathan Duckworth, and Renata Kokanovic. 2022. Mental Jam:
A Pilot Study of Video Game Co-creation for Individuals with Lived Experiences
of Depression and Anxiety. In ArtsIT 2021: Proceedings of the 2021 International
Conference on ArtsIT, Interactivity and Game Creation (Lecture Notes of the Institute
for Computer Sciences, Social Informatics and Telecommunications Engineering),
Matthias Wölfel, Johannes Bernhardt, and Sonja Thiel (Eds.). Springer Interna-
tional Publishing, Cham, 120–137. https://doi.org/10.1007/978-3-030-95531-1_9
[5] Mu-Hong Chen, Han-Ting Wei, Li-Chi Chen, Tung-Ping Su, Ya-Mei Bai, Ju-Wei
Hsu, Kai-Lin Huang, Wen-Han Chang, Tzeng-Ji Chen, and Ying-Sheue Chen.
2015. Autistic spectrum disorder, attention deficit hyperactivity disorder, and
psychiatric comorbidities: A nationwide study. Research in Autism Spectrum
Disorders 10 (Feb. 2015), 1–6. https://doi.org/10.1016/j.rasd.2014.10.014
[6] Ruth Elisabeth Cole. 2022. Compassion Fatigue and Burnout: When Caring Becomes
Too Much. DMin dissertation. Liberty University, Lynchburg, VA.
[7] Manuela Ferrari, Sarah V. McIlwaine, Gerald Jordan, Jai L. Shah, Shalini Lal,
and Srividya N. Iyer. 2019. Gaming With Stigma: Analysis of Messages About
Mental Illnesses in Video Games. JMIR Mental Health 6, 5 (May 2019). https:
//doi.org/10.2196/12418
[8] Mary Flanagan. 2009. Critical Play: Radical Game Design. MIT Press, Cambridge,
MA.
[9] Jane Friedhoff. 2013. Untangling Twine: A Platform Study. In DiGRA ’13 - Pro-
ceedings of the 2013 DiGRA International Conference: DeFragging Game Studies.
DiGRA, 1–10. http://www.digra.org/digital-library/publications/untangling-
twine-a-platform-study/
[10] Sabine Harrer. 2019. Radical Jamming: Sketching Radical Design Principles for
Game Creation Workshops. In Proceedings of the International Conference on
Game Jams, Hackathons and Game Creation Events 2019 (ICGJ 2019). ACM, New
York, 1–5. https://doi.org/10.1145/3316287.3316297
[11] Henry Jenkins. 2009. Confronting the challenges of participatory culture: Media
education for the 21st century. MIT Press, Cambridge, MA.
[12] Christian Sebastian Loh, Yanyan Sheng, and Dirk Ifenthaler. 2015. Serious games
analytics: Theoretical framework. In Serious Games Analytics: Methodologies for
Performance Measurement, Assessment, and Improvement, Christian Sebastian
Loh, Yanyan Sheng, and Dirk Ifenthaler (Eds.). Springer, New York, 3–29.
[13] Benjamin Nicoll. 2019. Minor Platforms in Videogame History. Amsterdam
University Press, Amsterdam. https://doi.org/10.1515/9789048540303
[14] Anne E. Robbins. 2015. A role for media in reducing the stigma of mental illness.
PhD dissertation. Alliant International University.
[15] Annika Simon. 2020. The Mountains We Make: Eine medienästhetische Analyse
psychischer Störungen in Celeste. In Krankheit in Digitalen Spielen: Interdiszi-
plinäre Betrachtungen, Arno Görgen and Stefan Heinrich Simond (Eds.). transcript
Verlag, Bielefeld, 189–210. https://doi.org/10.1515/9783839453285-010
[16] Anna Stenning and Hanna Bertilsdotter Rosqvist. 2021. Neurodiversity studies:
mapping out possibilities of a new critical paradigm. Disability & Society 36, 9
(Oct. 2021), 1532–1537. https://doi.org/10.1080/09687599.2021.1919503
[17] Jonah Warren. 2019. Tiny online game engines. In 2019 IEEE Games, Entertainment,
Media Conference (GEM). IEEE, New York, 1–7. https://doi.org/10.1109/GEM.
2019.8901975
[18] World Health Organization. 2017. Depression and other common mental disorders:
global health estimates. Technical Report WHO/MSD/MER/2017.2. World Health
Organization, Geneva. 24 pages. https://apps.who.int/iris/handle/10665/254610