Musings and reflections on contemporary and not-so-contemporary psychoanalysis.

The Challenge of Case Frequency in Psychoanalytic Training: How One Institute Has Come to Think About It

WomaninSnow

Since its inception in 1949, our Institute (now the Institute at PANY) has asked psychoanalytic candidate trainees to meet with their patients four to five times weekly. This frequency requirement has been reconsidered in recent years – within our organization, throughout the United States (the American Psychoanalytic Association [APsaA], American Association for Psychoanalytic Education [AAPE]), and indeed worldwide (International Psychoanalytic Association [IPA]).


A number of factors have influenced some institutes and associations to lower the frequency of sessions required during training. An important factor has been the competitive environment of mental health treatments that are less time consuming than analysis. Some of these treatments have actually been shaped and even spawned by the theory and successes of analytic work – so that institutes have become, in a way, "victims of their own success," in that more consumer choice has led to more challenges in finding patients interested in doing analysis. Other factors leading to the lowering of session frequency include contemporary changes in social and cultural sensibilities; popularization of "quick fixes;" economic considerations; and the idea that lowering frequency requirements will increase the numbers of applicants seeking psychoanalytic training and/or lessen some of the demands of training.


For over seven decades, most American analytic educators believed that the frequency per week of analytic sessions was directly proportional to the chances for the highest quality of analytic experience – both for the patient and for the candidate's education. While there are no studies that confirm these beliefs, the consensus of most practicing psychoanalysts has been that higher frequency tends to lead to more effective and lasting clinical results.


Currently, the analytic world is rethinking this widely-held belief. To be sure, the impetus for this is largely pragmatic (see next paragraph), thus creating a conundrum for both analytic educators and practicing analysts – involving practicality vs. the historical ethos of deeply valued time-honed notions concerning the best conditions for analytic process. Leaving aside the challenges that individual practicing analysts face, institutes, as educational organizations, face a special challenge.


As the Institute at PANY (formerly IPE), began to re-assess its current educational requirement of 4-5 times a week for candidates treating patients, we realized that the impetus was largely being driven by the kind of practical matters alluded to above: it is increasingly difficult for candidates to find patients who will work at the higher frequencies; the requirement seemed to impede candidate progression (more on this is elaborated below); and we were hearing rather consistently that potential applicants for analytic training were less willing to commit themselves to such a requirement. We were being seen as rigid.


But as we reluctantly embarked upon considering a reevaluation of this standard, we realized we had actually opened a door that invited us to look at something that perhaps we had taken for granted more than we would like to admit, something worthy of reconsideration – the supposition that higher frequency of sessions is considered to be better during training. And we began to see some of the important and complex issues that could be sequelae of this supposition, such as the possibility that we could be imparting to candidates and others a too rigid, insufficiently reflective stance that this frequency standard "just is what it is!"; or the observation that institutes may end up becoming excessively defined by the frequency of sessions they require.


In the light of this, in 2018, we put together a task force to study this subject of immersion and sought input from our Institute community – students and faculty. (The task force chaired by Michael Singer, D.O., included David Frank, MD; Sharon Lavon, LCSW; Jennifer Nogi, MD; Carmela Perez, PhD; Arden Rothstein, PhD; and Noah Shaw, MD).


The context for our conversations included general agreement that most practicing analysts who have graduated from analytic programs see some of their analytic patients three times weekly with success. The details of how graduate analysts conduct their practices are worthy of consideration, but our Institute-wide conversation was focused on the best way to educate our candidates. Education relates to how analysts ultimately practice; but education is also a special developmental experience unto itself, a kind of incubator.


What follows is based on PANY's many discussions, and the authors' reflections on the subject.


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What do we hope our candidates derive educationally from their supervised case work? We would like our students to experience being immersed in an in-depth analytic relationship; one that deals with intense and evolving transferences and counter-transferences; periods of gratifying insights and of confusion and ambiguity; stalled progress; both analyst and patient bearing varieties of emotional intensity; the often remarkable, unique experience and change than can result from only this kind of work; and all this, hopefully, with more than one patient.


The traditional approach of high frequency sessions has various underpinnings and rationales - including that while higher frequency of sessions does not in any way guarantee an analytic process, it increases the chances that a candidate will learn the value of greater immersion in inviting the full depth of an analytic experience and that the patient will experience greater therapeutic benefit. Some analysts feel it is not worth risking the loss of four or five times weekly frequency – that students should not be deprived of an opportunity that is at the very foundation of a psychoanalytic education - an opportunity that, even with high frequency, students partake of only in varying degrees. They believe that the value for the candidate's education and for the patient's treatment of a four to five times weekly frame is great – so much so, that when combined with an immersive analytic process, it is foundational for the professional development of the analyst. They feel that lower frequencies of sessions make it more difficult for the trainee to understand and track important elements in the flow of patient material, risking more intellectualized understanding and interventions at the expense of emotional attunement. They believe that the student who experiences such a supervised 4 to 5 times a week treatment has lived and learned through the depths of a treatment that will anchor and infuse clinical work (and teaching) for the remainder of his or her career. The ripple effect, or social network effect, upon that analyst's current and future patients as well as future students – so the argument goes - operates trans-generationally and is a serious consideration in thinking about the very survival and future growth of psychoanalysis and psychoanalytic educational institutions.


Below are some of the considerations that were pondered as PANY grappled with the subject, providing counterpoint to the argument from the preceding paragraph and leading to conclusions that support the following policy change.


We believe that higher (4 to 5 times weekly) frequencies are often best, and we will strongly encourage our candidates to have experience with their patients at these frequencies. But we also believe that allowing flexibility, when appropriate, for three times weekly frequency is a sensible educational approach. In fact, we feel that it is more than simply sensible – that it is actually a better approach during our current times. We therefore advocate in this essay for a range of frequencies of three to five times weekly as a standard for candidate education. For many reasons, any frequency below three times a week was not considered -mainly because such frequencies have a very low likelihood of allowing for the kind of continuity and immersive analytic process that is appropriate to serve as a standard for psychoanalytic training.


Here are some of the thoughts that support this new policy:


1) It was not clear to us, after thoroughgoing discussion, that the analyst's attunement referred to above is necessarily so contingent upon frequency, that there is necessarily such a strong correlation between frequency and being in touch with and immersed in what is relevant about the patient's underlying conflicts. There are too many variables in this regard, including the analyst's abilities and the success of his or her analysis, as well as the nature of the patient, that may well matter in addition to frequency.If an analyst has a tendency to intellectualize, he or she will probably have it at any frequency. And the antidote to the potential problem of analytic attunement that a candidate faces is to make sure our educators watch over and guide our students carefully enough to ensure that they gain an immersive experience in all aspects of their education, especially in their work with patients.


2) We would like to emphasize that the role of supervision and of the Student Progression Committee (SPC, which oversees the training of each candidate) is pivotal here. If the consensus of discussion within the SPC, informed by supervisory input (at PANY, supervisors attend SPC meetings for each senior candidate and, when indicated, for in-class candidates), is that the candidate is falling sufficiently short of an immersive experience with a particular patient at either 3, 4, or 5 times a week, this can be brought to the attention of the candidate in constructive ways that should enhance the candidate's education. This process, though, can only be effective to the extent to which the institute is functioning well, including having a faculty that shares a love for and devotion to psychoanalysis; an appreciation of the differences between psychotherapy vs. analytic process; a balance of rigor and tolerance; an appropriate ethos of SPC and institutional authority; and effective communication among the SPC, the supervisor, and the supervisee. The SPC needs to be able to interact with candidates and faculty in ways that address issues such as complaints of unfairness regarding different frequency considerations for different candidate situations. In certain respects, "the bar is raised" for SPC and supervisory work in the 3 to 5 times weekly model.


Furthermore, at PANY the SPC has always been guided by considering the qualitative aspects of candidates' clinical work more than by quantitative appraisals. PANY candidates are evaluated by their supervisors, SPC advisors, and by the entire SPC with regard to qualitative aspects of their work and are given regular feedback using specific guidelines. These guidelines were carefully developed so that candidates are provided with as clear and transparent feedback as possible - about their educational progress as analysts. The Elements of Psychoanalytic Competency comprise a group of skills that candidates are expected to demonstrate proficiency in, for graduation to take place. These skills include developing an analytic attitude and stance, self-awareness and self-assessment, interventional skills, conceptual skills - including an understanding of analytic process, written reports, and supervisory process. In addition to the competency criteria, PANY's delineation of Phases of Analysis includes additional significant qualitative elements regarding how each analysis that the candidate conducts progresses in time and phase. These qualitative appraisals are, in our judgment, fundamentally as important in thinking about candidates' development as the numbers of sessions per week.


3) The truth is, we don't know what is best for any given analytic pair when it comes to frequency. In principle, we assume – or like to believe – that candidates have more of a chance of learning best when they are more "immersed" in an analytic experience. While this is true, we have come to define "immersion" primarily as frequency. These terms seem to have become interchangeable – a premise that should be questioned. Immersion is better defined as the intense, unique experience that comes with an analytic process.


What facilitates immersion? The skill of the analyst is an important, relevant variable. Some students have greater skills "naturally;" some learn them as their own analyses progress and their defenses shift, their blind spots give way and they can empathize more freely. Experience is also a factor. A lot may depend on the candidate's own personal analytic experience and also on having patients that "take" to the analytic process and evolve within it. Some students have more luck in the types or quantity of referrals they are sent from the consultation and treatment service. In addition, certain patients will allow analysts-in-training to know them more easily than others will. And some analytic pairs and supervisor-supervisee pairs will work better than others. In other words, there are many variables that make for effective analyses and analytic learning. Frequency, albeit important, is only one of them. A three times weekly case might generate more or less analytic process than a four times weekly case, based upon these and other variables.


There are cases in which 4 to 5 times weekly treatment is preferable. Many examples could be offered. But, in our opinion, these appropriately higher frequency treatments should not preclude candidates from working with other patients who do not necessarily require or sufficiently benefit from the higher frequency to establish workable analytic process. Indeed, some patients may have more unworkable resistances at higher frequencies, especially when the candidate feels pressure to keep the patient in such a frequency because of an educational requirement (see # 11 below).


4) What about the relationship between continuity and immersion? Some believe that three times a week will not allow the continuity necessary for "deeper" work. Let's say someone comes Monday, Tuesday, Wednesday and there are then four days before the next Monday session; then there's the "Monday crust"; and by Tuesday it eases; and by Wednesday there's easier access; then there are another four days over which the continuity and momentum could be lost. This is a good argument against 3 times weekly. But not every patient has a "Monday crust". And suppose the 3x/week patient is coming Monday, Wednesday and Friday and working well? And what if a four times a week analysis has a three-day break? One could say that, generally, a 4 to 5 times weekly frequency does allow for less "crust" between sessions and for the patient to more readily incorporate analysis into his or her daily life - but again, the quality of the analysis will likely depend on the patient, the ability of the analyst and the fit, not just the frequency. And if continuity between sessions is an inhibiting factor, the candidate should have enough integrity – and the supervisor enough savvy - to work with the patient to increase the frequency, perhaps even to five times a week.


5) We feel there are risks involved in excessively objectifying or thinking reductionistically about the number of sessions per week. Patients and their analysts have varying capacities to establish, experience, and recall the flow of analysis from session to session. The experience of continuity or discontinuity of the flow of material through time by analyst and patient is shaped by the actual session frequency but is also highly subjective and relative - based on many factors. Time and frequency take on different meanings for different patients and at different phases of a single treatment. We may selectively overlook or disregard the fine-grained meanings associated with the use of time if we think excessively and/or rigidly about lines of demarcation regarding frequency.


To what extent could frequency come to be linked in the analyst's mind as foundational for training because it has been paired with process in ways that some analysts over-weigh, and in so doing selectively under weigh other sources of analytic process? As important and valuable as we believe that higher frequency treatments are - in training and clinical practice - we are concerned that the 4-5 number has come to serve as a kind of magnet for all sorts of feelings that analysts have about doing analytic work, not all of which are necessarily rational. If we think there may be transferences that all analysts have to the extraordinarily challenging discipline that we practice, to each other, and to our organizations, we need to think seriously about the rational as well as the irrational ways that we experience the various approaches to thinking about time and frequency. We feel that different frequencies constitute important framing entities that need to be carefully considered in every analysis - and conflicts about them need to be analyzed when necessary. But we worry that a kind of politicization has developed within our field that can lend a fraught quality to conversations about frequency. Perhaps frequency considerations have become more definitional of the entirety of analysis (a kind of pars pro toto thinking) than they need to be, as we train candidates - so that we end up concretizing 4-5 sessions per week in a compulsory and even idealized fashion that does not sufficiently take into account the extraordinary variety in the psychoanalytic enterprise. Perhaps it is not as vitally important as some think, and perhaps this sort of thinking could exert unintended consequences on how candidates come to feel about the field of psychoanalysis. Examples might include candidates' reactions to what might be perceived as elitism and/or rigidity on the part of faculty, leading to forms of alienation that are not good for the profession.


Finally, and perhaps parenthetically, it may be that frequency considerations risk defining institutes and associations more than they should.


6) On a practical level we believe that, in certain real ways, seeing patients four to five times per week during candidacy poses special challenges that are different now than decades ago within our New York City community. To name a few: considerations of time and money for candidates, some raising young families, have changed; diluting patient fees by a factor of four or five, versus three, is more difficult now than in the past; the difficulties posed by candidates commuting to and fro from homes outside of Manhattan (more candidates now live outside of Manhattan because of relatively higher costs of housing and educating their children than in the past), and traveling around an increasingly congested city for supervision, among other factors, all pose more obstacles than in the past. The opportunity costs of time and money are greater now. This is the reality of contemporary training, and in our experience, does not necessarily stem from candidates' prioritizing money over patients. We believe it is important for Institutes to demonstrate empathy for the particular challenges candidates currently face, some of which are different from what faculty faced during their own training.


7) Senior candidates and recent graduates at PANY indicated that they deeply valued having had the opportunity to work with patients four to five times weekly, even though they were not able to understand, up front, at the earlier stages of their training, why they were recommending four times weekly treatment to their patients. But these same candidates and recent graduates expressed frustration or regret that they had not had the experience, while in training, of seeing their patients three times weekly under supervision. They also expressed a related but different issue: the demoralization and resentment that can stem from stalled progression through candidacy that might have been averted or lessened by allowing three times weekly cases. They expressed resentments about having to take our word that higher frequencies are best; or about feeling forced to treat all their patients four times a week - while making their own lives more difficult; or resentments about progression and graduation being put on hold because of difficulties finding four times weekly cases.In listening to our candidates, we feel it is unfair to dismiss these sorts of concerns as necessarily indicating signs that the candidate is either fighting the Institute for his or her own neurotic reasons or because of other issues that the Institute might label as a particular candidate's educational lag. Is it worth putting a drag on candidates' progression if they have the ability and have some patients who can achieve an immersive treatment process in less than 4-5 times per week analyses?


8) Another question we debated: how is it possible during candidacy, that brief part of an analyst's learning trajectory, to learn what is needed to develop competence as a psychoanalyst? Most of us believe that the Eitingon tripartite model (personal analysis, classroom work, and supervision) works well for candidate education. We want the various aspects of this model to complement each other and to be integrative - but this works unevenly for most students. We may be idealizing what candidates can learn during the few years we have them as students. Candidates will treat perhaps one or two patients for more than three to four years while they are in training.This time span will usually be short of the time it takes to reach the deeper middle or even end phases when much of the psychoanalytic process we hope for happens. Although the short time span of candidacy could be seen as a rationale for requiring higher frequencies, it can also be seen as a need that educators have – an institutional ego ideal, so to speak – for more rapid development than is often possible during the relatively brief period of candidacy, especially when one considers how long it takes for most of us to develop into psychoanalysts.


9) And if we idealize what candidates can learn while we have them as students, perhaps, correspondingly, we insufficiently trust the motivation for lifelong learning and postgraduate development that can spur our recently graduated analysts to work at more intensive frequencies.Indeed, part of the rationale for IPE (whose prior mission was candidate education) merging with the PANY Society (whose prior mission was postgraduate education), to form a new umbrella organization we now call PANY was to provide a greater sense of continuity, integration and momentum between formal, "undergraduate" psychoanalytic training and post-graduate learning. Building bridges between candidacy and postgraduate learning is important to help our recent graduates continue to develop their analytic identities and careers.


10) Another issue we struggled with was: if our Institute endorses three times weekly treatments as the educational platform, will candidates "take the easy way out" and opt to treat all their patients at this lower frequency?


Our conclusion was that this represents a cynical viewpoint that underestimates the organic nature and the power of how an immersive, well-conducted analysis develops. It might be true for some candidates that if four to five times weekly treatments are not "enforced," they will never allow themselves and their patients the experience. Realistically, there will probably be some 3 times weekly treatments that in the past would have been 4 times weekly. But we also considered the value of the approach of openness in keeping the frequency anywhere between three and five times weekly.Factors that can mitigate against candidates automatically opting for the "easier route" should emerge from an Institute and supervisory ethos that respects the spirit of a well-functioning analytic treatment at 3, 4, or 5 times a week. We trust that candidates and supervisors will decide what is best for any individual patient, and that they will be able to openly consider when a resistance to an increased frequency (if an increase seems indicated) is being determined by an interest in expediency or by accessible internal conflict on the part of the patient or analyst. Candidates may well see that an increase in the frequency is naturally indicated as the process deepens or may see that the process is not being afforded an opportunity to deepen because the frequency is not adequate.Conversely, it may be that the higher frequency is posing an insurmountable resistance, at least for the time being, in allowing for a more effective analytic process. Candidates may choose to conduct 4 to 5 times weekly treatments if we trust the patient's (and analyst's) appropriate wishes for more frequent sessions, and trust the momentum of successful analytic process to deepen (including in frequency). The supervisor can initiate the conversation about frequency with neutrality. There may be great clinical as well as educational value to supervisory openness in regard to supervisor-supervisee conversations about the frequency of sessions. Ultimately, we prefer to trust and respect openness in each student analyst/patient and each student analyst/supervisor couple that will lead to the best choice in each situation.


11) We also considered that legislating four to five times weekly treatments may even in some instances operate against these treatments emerging; as opposed to a trusting model that allows for a gradual deepening of analytic process without a legislative requirement. It is also possible, for some, that the use of rules requiring the traditional 4 to 5 times per week requirement could mask insufficient trust in the power of unlegislated analytic momentum in a well conducted treatment to gravitate towards deeper immersion.


Consider the following: a single required frequency can put the pressure of a requirement on a candidate, one that may lead to un-analytic modes of influence in pressuring the patient to comply (precisely at a time in their development when candidates are usually near the start of their learning curve regarding the development of an analytic attitude). This Institute approach could have a ripple effect on the supervisor, the student's advisor (Student Progression Committee advisor) and in fact the entire Student Progression Committee - putting differing layers of individuals and groups in roles that, when added up, may constitute a matrix of pressuring or insistence.In supervision, this can be bilaterally experienced: variations of pressuring or hurrying that can lead to all sorts of problematic consequences that may not be in the interests of the student analyst's, and more importantly, of his or her patient's development. One example would be that a candidate could actually end up not treating a three times weekly patient because of an Institute requirement for greater frequency – so that the analytic couple never has a chance to grow into 4 or 5 times weekly treatment; or a candidate rushes a patient along to increase the frequency, even in subtle ways that might compromise the natural, well-working rhythm that an analytic couple establishes. This tempo of analytic development can sometimes take years even with experienced analysts; it's probably too much to expect from a candidate in many instances. Though it is true that institutes have educated candidates for many years even with these drawbacks, which can sometimes be mitigated by thoughtful reflection among the Institute participants concerned, our own experience suggests that this is a difficult task that not infrequently can go awry.


In addition to effects upon the candidate experience, we should not underestimate the longer-term complications of how graduates come to feel about psychoanalysis and about their institutes when their candidacy has been protracted or demoralizing because of case finding difficulties related to the dynamics of authority and opposition described above.


12) The candidate's own training analysis: Our faculty struggled with the following legitimate question:If we change the frequency to some version that includes three times per week for students treating their control cases, are we contradicting ourselves if we insist that 4 to 5 times a week is necessary for the candidate's personal analysis? We recognize there are some who would argue that this is a significant contradiction.


However, we believe there are challenges faced by candidates in their professional lives, as they conduct analyses and as they enter the lifelong process of becoming analysts, that are substantively different from the challenges our non-analyst patients face; so that because a candidate may treat some of his or her patients at three times a week, it does not stand to reason that the candidate's own analysis should be conducted at three times a week.


Certainly, both control cases and the candidate's own personal treatment need to be therapeutic, and they overlap substantially in many of their aims, but they also differ in important respects. There are unique challenges faced by psychoanalysts in their clinical work, particularly understanding and managing their countertransference reactions; uncovering their blind spots; and internalizing self-analytic abilities. While both the candidate and non-candidate analysand hopefully, will meet these challenges, there are significant and necessary qualitative and quantitative differences and expectations for the candidate's analysis. And there is still something to be said for the "training" part of the training analysis: candidates learn something about being an analyst from their analyst and identify with his or her analytic function and attitude. There is, as well, the special challenge of the candidate treating his or her own patients contemporaneously with being in analysis. All of this seems to us to warrant a 4 to 5 times weekly analysis during this (most likely) one-time experience for analysts in training.


Our efforts as educators are to do our best to ensure that the trainee is prepared to do the extraordinarily complex work of analysis in a competent manner over a career of widely varied clinical contacts. If there is only one analytic experience for the candidate who has a unique learning responsibility, not just a personal therapeutic one, let it be at the higher frequency.


This frequency also keeps the door open for the candidate to eventually become a training analyst in institutes that currently require that TA's have been treated in their own personal analysis at 4-5 times weekly. Candidates may not have the perspective to recognize this sort of personal career choice when they are starting their analyses early in training, and could unwittingly foreclose future career options if they are in less frequent personal treatment.


Finally, while the candidate can have many patients at various frequencies during training and will have the opportunity to compare, he or she usually has only one training analysis. The argument that we send the wrong message, or mixed messages, to candidates in not also claiming that the candidate's patient has only one analysis and therefore should be afforded the same frequency as his or her analyst, strikes us as involving a kind of "even-steven" thinking - putting aside the fact that the candidate is free as well as encouraged to offer 4-5 times treatments for all of his or her cases when appropriate. And to the extent to which some candidates may interpret this as mixed messaging, we feel that the overall gains in other areas considered in this essay provide sufficient counterweight to offset this possibility.


We therefore recommend that the experience of analytic immersion for a candidate's own personal analysis be conducted at a frequency of at least four times a week.


13) Some of our faculty have expressed concerns that if educational requirements for the frequency of sessions continue to be lowered, psychoanalysis will lose its differentiation from psychotherapy, and in so doing, lose its power as a treatment and its identity. They point to the dilution of treatment standards in general practice over the last 40 years – from 50-minute sessions to 45-minute sessions; from 5 times per week to 4 times a week to 3 times per week. They fear a continued process that threatens to whittle away our discipline and believe, without devaluing psychodynamic psychotherapy as a treatment and as a training, that some psychoanalytic institutes have essentially become psychotherapy institutes.


The response to these concerns is to take them seriously. Our faculty needs to remain mindful of the substantial qualitative differences between psychodynamic psychotherapy and psychoanalysis as we educate our candidates. Both disciplines are valuable and effective. But they are by no means identical. As mentioned earlier, frequencies below three times a week would by almost all estimations be insufficient for the kind of continuity and immersive analytic process necessary to be considered a psychoanalysis (not that our prior frequency requirements of four times weekly sessions haven't precluded treatments that became, essentially, "psychotherapy on the couch" as opposed to psychoanalysis).


One recent PANY program change that might be helpful here, is hosting shared clinical presentations and case discussions, in which both our psychotherapy program and psychoanalytic program candidates participate together –the entire enrolled community having the chance to hear students and faculty comment on clinical work from the frameworks of each respective approach. These conferences are now regularly scheduled on the academic calendar and will invite us to think more deeply about the continuities and differences between dynamic psychotherapy and psychoanalysis.


14) In adopting the plan of openness regarding treatment occurring between 3 and 5 times weekly, we believe it is important to continue to discuss this in different forums of our Institute life: in Student Progression Committee and EC meetings; during candidate orientation; in individual supervision of candidates; in the classroom; in our Candidate Manual; on our website ; during outreach efforts and in open houses; and in our postgraduate activities – from faculty symposia and conferences to supervisors' meetings. And then after some years of experience, we'll make our best effort to appraise the results.




David Frank, M.D., Director, PANY

Michael Singer, D.O., Past Director, PANY

January, 2019 

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September 15, 2019

Psychoanalytic Association of New York
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