The book opens with a vivid scene of Elyn having a psychotic episode, introducing two seemingly disparate aspects of Elyn’s identity: she is a student at a prestigious law school, and she has a severe mental illness. The choice of scene to include in the prologue is significant, especially as throughout her journey, Elyn grapples with reconciling these different selves for herself. Throughout, the book explores ideas of self and identity in the context of mental illness.

Early on, Elyn is presented as someone who is strong-willed and independent. This is reiterated by her display of defiance in situations where she sees her autonomy being threatened, even when her defiance causes her own suffering. It is what solidifies her image as a difficult patient, as she chooses to sing all night long when she is put in restraints. Elyn’s extraordinary intelligence (as evidenced by her numerous academic and professional achievements) contributes to her feelings of self-worth. Being a high-achieving scholar is the most important identity she inhabits, and anything that threatens this causes her deep anxiety. Hence, Elyn’s initial struggles with her illness beyond its direct symptoms is the threat it poses to her sense of self.