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\title{Clinical Signature among Victims of Intimate Partner Violence: A Study using Text Classification Tools}
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             \author[1]{Luciane Maria  Both}

             \author[2]{Lúcia Helena Machado  Freitas}

             \author[3]{Ives  Passos}

             \affil[1]{  Federal University of Rio Grande do Sul}

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\date{\small \em Received: 8 December 2019 Accepted: 5 January 2020 Published: 15 January 2020}

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\begin{abstract}
        


Introduction: Intimate partner violence is a major public health problem and a violation of women's human rights. It is important to explore the speech of the victim at the time of the complaint.Method: It is a text classification study with a word cloud analysis technique, complementing the qualitative analysis. The sample is fifty-six women victims of self-reported domestic violence, who came from a public service in South of Brazil.Results: A word cloud was developed from the speech of the 56 participants.Discussion: The women's discourse in the interviews had focused on understanding what had really happened in their relationship, reporting their abusive situations. Studies using this technique benefit from including heterogeneous patients considering their idiosyncrasies to develop a complex non-linear pattern relating predictors to the clinical outcome.

\end{abstract}


\keywords{intimate partner violence, word cloud, qualitative research.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
iolence against women, particularly intimate partner violence (IPV) is a major public health problem and a violation of women's human rights. Worldwide, 35\% of women who have been in a relationship have experienced physical and/or sexual violence by their intimate partner. Based on World Health Organization data, women's lifetime exposure to intimate partner violence is associated with myriad health outcomes, like fatal outcomes, lead to injuries, depression, post-traumatic stress and other anxiety disorders, sleep difficulties, eating disorders, and suicide attempts (WHO, 2017). Not surprisingly, IPV is the second most common risk factor for disabilityadjusted life years globally in women aged 20-24 years \hyperref[b16]{(Mokdad, 2016)}.\par
IPV is challenging to identify and address. Healthcare professionals play a significant role in identifying women who are usually exposed to domestic violence, identifying the signs of violence, protecting victims from experiencing violence again, and providing support to victims (Yaman  {\ref Efe, 2012)}. Considering the significance of the issue, it is important to explore the speech of the victim at the time of the complaint, what are the most representative aspects in his speech, since it has been about violence for years. Why did you report it now? Which treatment is best suited to your needs?\par
We began to explore the victim's discourse to develop a model to understand the real needs of these victims at the time of reporting. Thus, patients benefit from more accurate treatment plans, avoiding prolonged periods of "trial and error" seeking the correct treatment to avoid revictimization, because women victims of domestic violence have difficulties in adhering to some treatment. The present study aims to analyze the text classification with word cloud as a tool to understand the pattern of patient functioning, complementing the qualitative analysis. 
\section[{II.}]{II.} 
\section[{Methods a) Study design}]{Methods a) Study design}\par
It is a text classification study with a word cloud analysis technique, complementing the qualitative analysis. It is complementary to a larger research, still in progress. 
\section[{b) Sample}]{b) Sample}\par
Fifty-six women victims of self-reported domestic violence, who came from a public service in South of Brazil. We included all women who were present on collection days in December 2017 and agreed to participate in the study. 
\section[{c) Instrument}]{c) Instrument}\par
We collect sociodemographic data from women such as: age, schooling level, family income, time of marital relationship, living with, use of drugs, existence of parental violence (transgenerationality of violence), among others. We also conducted the Operationalized Psychodynamic Diagnosis (OPD-2) Clinical Interview (Task Force, 2016). It is a semi-structured interview with specific interviewing tools for the exploration of each axis: I) "Module for the Evaluation of Domestic Violence OPD" proposed by the Chilean researcher Carla Crempien in 2009 in her PhD thesis \hyperref[b6]{(Crempien, 2009}\hyperref[b7]{(Crempien, , 2012) )} and adapted to Brazil (Both et al. 2019), II) dysfunctional interpersonal pattern, III) intrapsychic conflicts, IV) structural functions (Task Force, 2016). 
\section[{d) Data analysis}]{d) Data analysis}\par
Python code was used as a base, which is available through the link https://www.geeksforgeeks. org/generating-word-cloud-python/. All prepositions and conjunctions were removed for the construction of the cloud.\par
III. 
\section[{Results}]{Results} 
\section[{a) Study population}]{a) Study population}\par
The sample had normal distribution (p <0.05). The participants were 56 women aged 18-65 years (mean: 30, 07 years) who educational levels ranged from high school, income between 1 and 2 salaries. Table \hyperref[tab_0]{1} presents the socio-demographic characteristics of the participants. The length of the marriages was in the range of 1-30 years, and 46, 4\% were separated in less than 6 months (Table \hyperref[tab_1]{2}). Duration of violence is described in Table \hyperref[tab_2]{3}. Note. Income: 1 salary is a basic remuneration to the worker. Religion: Godless is the person who do not believe in God. Spiritism is the person who believe in life after death. Umbanda is the person who has several cults influenced by Indians.     
\section[{Discussion}]{Discussion}\par
According to Wild and collaborators (2018), evidence suggests that knowledge and skills rarely translate international guidelines and sustainable good practice. It is necessary to change support training and health leadership. For example, the National Action Plan on Gender-based Violence in Timor-Leste for training of trainers (SEM, 2017), WHO handbook for engaging health (WHO, 2017). Therefore, professionals and researchers need to understand the real needs during the reception and identification of women suffering from IPV.\par
The women's discourse in the interviews had focused on understanding what had really happened in their relationship, reporting their abusive situations. In this sense we highlight the words "problem", "people" referring to the couple, "he", "his", what was said ("said"), the children involved ("son", "daughter", "child").\par
All women referred to the "beginning" of the relationship as different, whose husband was affectionate and caring, but over time this behavior changed. The husband had jealous and controlling behavior. This aspect is observed in the cycle of violence. Intimate partner violence tends to be systematic and chronic, the maltreatment goes through cycles in which violence episodes alternate with remorse and recompense; this has been described as the "cycle of violence". IPV increases on severity along time  {\ref (Walker, 2016)}.\par
In this sense, they concentrate part of the discourse reporting the cause ("cause") of the violence. They attributed her husband's use of alcohol and drugs and her husband's jealousy that provoked aggression in his behavior. According to \hyperref[b28]{Zacan et al. (2013)} and \hyperref[b6]{Crempien (2009)} husband's drug use and jealousy is a relevant factor in IPV. This control is called psychological violence \hyperref[b2]{(Brasil, 2006)}. Women who suffered psychological violence reported significantly more controlling behaviors from their partners than nonvictims. And from a clinical perspective, it has been reported its impact on women's mental health, and its associations with depression, anxiety and posttraumatic stress disorder (García-Moreno, Jansen, Ellsberg, Heise, et al, 2006). The cause is also noted by the word "think" in the word cloud, in which participants tried to exploit partner violence.\par
Research suggested that social support is associated with less severe IPV (Schultz, Walls, \& Grana, 2019, Crempien, 2012), specially with family \hyperref[b26]{(Wright, 2015)}.However, it is observed that the victim's speech was organized around the husband (words "he", "his", "father" of the children). Little said too much social relationships with friends or family. Another prevalent speech was the word "mother", but they referred in a negative sense, angry at early abandonment, lack of support. Also, companions limit them in relation to having a job, where they remain focused on raising children at home \hyperref[b1]{(Blanchard et al., 2018)}.\par
Studies point to the trangerationality of violence, whose father's perpetration of violence against the mother and child (Chiesa et al., 2018), with a cooccurrence rate of 75\% (range 11-97\%; Jouriles, McDonald, Slep, Heyman, \& Garrido, 2008). There are many consequences for children exposed to IPV in mental and behavioral health \hyperref[b11]{(Johnson et al., 2002}\hyperref[b15]{, Lapierre, 2010}\hyperref[b7]{, Crempien, 2012)}.\par
Another word that stood out in the word cloud was the word "fear." The male perspective is characterized by abusive and coercive physical or nonphysical conduct, with recognizable inequality of powers and play of forces. And regarding female behavior, there is the presence of fear with response of avoidance, adaptation and submission \hyperref[b6]{(Crempien, 2009;}\hyperref[b1]{Blanchard et al., 2018)}. IPV presents with a slow and silent onset without physical aggression and gradually progresses to actions with greater intensity and humiliation  {\ref (Leôncio et al., 2008)}. However, violence can be aggravated due to women's shame in reporting, lack of educational means and access to legal information and lack of assistance and protection  {\ref (Signori, \& Madureira, 2007)}. In this sense, it is necessary to combine effective assessment practices with preventive measures, such as psychoeducation and other screenings.\par
V. The aim of this study was to analyze the text classification with word cloud as a tool to understand the pattern of patient functioning, complementing the qualitative analysis. Thus, it was observed that it was possible to explore various questions of the participants using the word cloud. 
\section[{Text Classification Tools}]{Text Classification Tools} 
\section[{VI. Implications for Clinical Practice and Public healthy}]{VI. Implications for Clinical Practice and Public healthy}\par
According to a meta-analysis, there is an association between IPV and mental health problems domestic violence are post-traumatic stress disorder, anxiety disorder, and depression \hyperref[b4]{(Cengiz et al., 2014)}. High levels of IPV are associated with moderate suicide risks \hyperref[b13]{(Kavak et al., 2018)}.\par
During the reception of women, it is important to differentiate episodes of recent violence and violence that has occurred historically in women's lives, the duration and severity of IPV, risks of alcohol and other substance use, support network (Bacchus, Ranganathan, Watts, Devries, 2018). IPV is associated with a history of childhood trauma. Abusive experiences during childhood predispose victims to a higher risk of later revictimization. Thus, previous traumas resurface in current traumas that need to be elaborated and overcome dependence valuing their self-esteem (Sahin, Timur, Ergin, Taspinar, Balkaya, Cubukcu, 2010).\par
VII. 
\section[{Conclusion}]{Conclusion}\par
This study was bold because it used text classification as a method of qualitative analysis. It was possible to understand the pattern of patient functioning from the text classification tool. Of particular importance to the population of this study, more research using word cloud to understand the mechanisms by which IPV may influence mental health.\par
A limitation of this study is its cross-sectional nature which impedes the establishment of temporal relations between the studied variables or the study of the self capacities, later to victims' reparation therapy and interdisciplinary interventions. Another limitation is the small sample size, where there are no subgroups to compare variables.\par
The risk for IPV and the ability to buffer effects of traumatic stressors on health outcomes is higher when the discourse of victim focuses only on the traumatic event. It is necessary to accommodate the patient's demand to understand the situation of violence, elaborate these issues and insert different interests (work, protection services, support network). Thus, it was possible to contribute to the enrichment of their difficulties and the treatment obstacles. Working through with the victim on these aspects, could lead to a more complete and realistic perception of herself and the others', as well as promoting her reflective function and affective regulation.\par
The violence or a consequence of it represents internal obstacles of the victim to regulate her emotional experience and stress. The treatment could contribute to the management in a differentiated way, diverse self capacities. Future research is recommendable to include a larger number of participants in order to go further in the study of these possible associations. Likewise, longitudinal studies are interesting to examine changes in self capacities during interventions. 
\section[{VIII.}]{VIII.} 
\section[{Ethical Observations}]{Ethical Observations} 
\section[{Conflicts of interest:}]{Conflicts of interest:}\par
There are no conflicts of interest. 
\section[{Ethical Approval:}]{Ethical Approval:}\par
The work was approved by an institutional ethics committee and authorized to collect data at the corresponding institution.\par
3. Consent: The victims were invited voluntarily and authorized their participation in the research by signing the Term of Free and Informed Consent.\par
4. Omission: All data that could identify participants was omitted.\begin{figure}[htbp]
\noindent\textbf{1}\includegraphics[]{image-2.png}
\caption{\label{fig_0}Figure 1}\end{figure}
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\noindent\textbf{1} \par 
\begin{longtable}{P{0.030493273542600896\textwidth}P{0.37544843049327353\textwidth}P{0.21980568011958146\textwidth}P{0.2242526158445441\textwidth}}
Category\tabcellsep Subcategory\tabcellsep Women\tabcellsep Men\\
\tabcellsep 18 to 20 years old\tabcellsep 8 (14,3\%)\tabcellsep 3 (5,4\%)\\
\tabcellsep 21 to 25 years old\tabcellsep 16 (28,6\%)\tabcellsep 5 (8,9\%)\\
\tabcellsep 26 to 30 years old\tabcellsep 8 (14,3\%)\tabcellsep 16 (28,6\%)\\
\tabcellsep 31 to 35 years old\tabcellsep 9 (16,1\%)\tabcellsep 13 (23,2\%)\\
Age\tabcellsep 36 to 40 years old 41 to 45 years old\tabcellsep 8 (14,3\%) 2 (3,6\%)\tabcellsep 4 (7,1\%) 5 (8,9\%)\\
\tabcellsep 46 to 50 years old\tabcellsep 3 (5,4\%)\tabcellsep 5 (8,9\%)\\
\tabcellsep 51 to 55 years old\tabcellsep 1 (1,8\%)\tabcellsep 1 (1,8\%)\\
\tabcellsep 56 to 60 years old\tabcellsep 1 (1,8\%)\tabcellsep 2 (3,6\%)\\
\tabcellsep 61 to 65 years old\tabcellsep 0\tabcellsep 2 (3,6\%)\\
\tabcellsep White\tabcellsep 37 (66,1\%)\tabcellsep 35 (62,5\%)\\
Race\tabcellsep Black Brown\tabcellsep 21 (21,4\%) 6 (10,7\%)\tabcellsep 13 (23,3\%) 7 (12,5\%)\\
\tabcellsep Indigenous\tabcellsep 1 (1,8\%)\tabcellsep 1 (1,8\%)\\
\tabcellsep Illiterate\tabcellsep 0\tabcellsep 1 (1,8\%)\\
\tabcellsep Incomplete elementary school\tabcellsep 15 (26,8\%)\tabcellsep 17 (30,4\%)\\
\tabcellsep Complete primary education\tabcellsep 6 (10,7\%)\tabcellsep 6 (10,7\%)\\
Scholarity\tabcellsep Incomplete high school Complete high school\tabcellsep 8 (14,3\%) 22 (39,3\%)\tabcellsep 7 (12,5\%) 22 (39,3\%)\\
\tabcellsep Incomplete higher education\tabcellsep 3 (5,4\%)\tabcellsep 1 (1,8\%)\\
\tabcellsep Complete higher education\tabcellsep 1 (1,8\%)\tabcellsep 2 (3,6\%)\\
\tabcellsep Postgraduate studies\tabcellsep 1 (1,8\%)\tabcellsep 0\\
\tabcellsep None\tabcellsep 13 (23,2\%)\tabcellsep 8 (14,3\%)\\
\tabcellsep Less than 1 salary\tabcellsep 8 (14,3\%)\tabcellsep 1 (1,8\%)\\
Income\tabcellsep Between 1 and 2 salaries Between 3 and 6 salaries\tabcellsep 31 (55,4\%) 2 (3,6\%)\tabcellsep 35 (62,5\%) 5 (8,9\%)\\
\tabcellsep Between 7 and 12 salaries\tabcellsep 1 (1,8\%)\tabcellsep 2 (3,6\%)\\
\tabcellsep More than 12 salaries\tabcellsep 1 (1,8\%)\tabcellsep 4 (7,1\%)\\
\tabcellsep Godless\tabcellsep 22 (39,3\%)\tabcellsep 26 (46,4\%)\\
\tabcellsep Catholic\tabcellsep 19 (33,9\%)\tabcellsep 15 (26,8\%)\\
Religion\tabcellsep Spititist\tabcellsep 4 (7,1\%)\tabcellsep 3 (5,4\%)\\
\tabcellsep Afro-Brazilian\tabcellsep 3 (5,4\%)\tabcellsep 6 (10,7\%)\\
\tabcellsep Evangelical\tabcellsep 0\tabcellsep 6 (10,7\%)\\
\tabcellsep Alcohol\tabcellsep 3 (5,4\%)\tabcellsep 25 (44,6\%)\\
Addiction\tabcellsep Drug Tobacco\tabcellsep 2 (3,6\%) 8 (14,3\%)\tabcellsep 0 7 (12,5\%)\\
\tabcellsep Marijuana\tabcellsep 1 (1,8\%)\tabcellsep 7 (12,5\%)\end{longtable} \par
 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.09066666666666667\textwidth}P{0.4892222222222222\textwidth}P{0.2701111111111111\textwidth}}
Category\tabcellsep Subcategory\tabcellsep Women\\
\tabcellsep Date\tabcellsep 1 (1,8\%)\\
\tabcellsep Dating\tabcellsep 9 (16,1\%)\\
Type of relationship\tabcellsep Marriage Stable union\tabcellsep 5 (8,9\%) 8 (14,3\%)\\
\tabcellsep Divorced\tabcellsep 7 (12,5\%)\\
\tabcellsep Separated in less than 6 months\tabcellsep 26 (46,4\%)\\
\tabcellsep Less than 6 months\tabcellsep 3 (5,4\%)\\
\tabcellsep Between 6 months and 1 year\tabcellsep 6 (10,7\%)\\
\tabcellsep Between 1 and 2 years\tabcellsep 11 (19,6\%)\\
Time of relationship\tabcellsep Between 3 and 5 years Between 6 and 10 years\tabcellsep 13 (23,2\%) 15 (26,8\%)\\
\tabcellsep Between 11 and 15 years\tabcellsep 2 (3,6)\\
\tabcellsep Between 16 and 20 years\tabcellsep 4 (7,1\%)\\
\tabcellsep Between 21 and 30 year\tabcellsep 2 (3,6\%)\end{longtable} \par
 
\caption{\label{tab_1}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.41779661016949154\textwidth}P{0.43220338983050843\textwidth}}
Category\tabcellsep Frequency\\
< 6 months\tabcellsep 18 (32,1\%)\\
6-24 years\tabcellsep 8 (14,3\%)\\
2\tabcellsep \end{longtable} \par
 
\caption{\label{tab_2}Table 3 :}\end{figure}
 		 		\backmatter   			 
\subsection[{Acknowledgment}]{Acknowledgment}\par
This study was supported by the Legal Medical Department of Rio Grande do Sul, especially by Dr. Anlelita Rios, who invited and made collection possible at the institution. 			  			 
\subsection[{Funding information}]{Funding information}\par
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