The book chronicles Autumn's experiences in a modern-day psych ward as well as those of a fictional young girl, "Emily-with-a-y", in Victorian England who is admitted into an insane asylum.

Told through the form of journal entries, the novel begins with Emilie's suicide attempt and subsequent forced admission to a psych ward.

Emilie begins to describe the events of her life that led to her suicide attempt, including abuse she suffered both as a child and in her romantic relationships, and her experiences with bipolar disorder.

Emily describes being born into poverty and joining the Unfortunate Girl's Music Conservatoire at a young age, where she is trained as a violinist.

When Emily grows up, she learns that the Conservatoire is a front for a form of human trafficking where young girls are only trained to be sold to the highest bidder.

Emily begins to wander the streets of London and is soon arrested and taken into the custody of Madame Mournington, the headmistress of the Asylum for Wayward Victorian Girls.

However, the key that Anne gave Emily begins to glow and takes on supernatural powers, and is inexplicably able to open the Asylum gates.

She goes back through the previous letters only to find that they are all actually made of brown paper towel from the hospital bathroom, incoherently scribbled over with red crayon.

As a partially autobiographical work, the book is based heavily on Autumn's experiences with bipolar disorder, psychiatric hospitalization, abuse, and misogyny.

[7] In July of that year, Autumn released the album Fight Like a Girl, which is based on the events of the book, and which she referred to as a "preview" of the musical.