Emotional abuse and incest are major themes of this book, but the incest is mostly shown through abstraction, and it isn't explicit. The title character has visions of violence and attempting suicide, which is gory. Her pet rat also dies over the course of the book, leading to it being internalized as her imaginary friend. Despite this, the book isn't that intense; it is absolutely appropriate for teenagers.

That said, her rat accompanies her through the entire book as a positive presence. It appears even on the end papers, showing their happy ending together.