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Powerpoint Templates
James Tobin, Ph.D.
Licensed Psychologist PSY 22074
220 Newport Center Dri...
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Page 2
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“His mother is enmeshed
with this boy and he needs to
differentiate from her.”
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Page 4
“The violin is a surrogate sibling
for the boy that he must give up
in order to mourn the deat...
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Page 5
“The father’s abandonment
probably left the boy with
ambivalence about his own
masculinity. Th...
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Page 6
“Why can’t he do both?
Go to college then in the summers
go to Europe for his musical
training...
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Page 7
I Thought our Field Aspired to Avoid Premature
Conclusions or Erroneous Assumptions?
Perhaps i...
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Page 8
Nietzche
Nietzche (1873/1999, as cited in Kose, 2003, p. 214): “ ... all
knowledge is „nothing...
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Page 9
“Instrumental Fictions”
In Between Conviction and Uncertainty:
Philosophical Guidelines for
Pr...
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Page 10
Knowing So We Don‟t Have to Think
“A lot of us use (or misuse) theories, articles we have rea...
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Page 11
The Reduction of Uncertainty is a
Neurocognitive Certainty
There is a burgeoning literature o...
Powerpoint Templates
Page 12
The Need to Reduce Uncertainty: Anxiety
(1) Anxiety emerges when there is a mismatch
between ...
Powerpoint Templates
Page 13
The Need to Reduce Uncertainty: Structured
Thinking
(2) Emotions associated with appraisals o...
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Page 14
The Need to Reduce Uncertainty: Dogmatism
(3) ... “by willfully ignoring information that
con...
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Page 15
Evidence-Based Practice (EBP)
Ours is an environment of EBP, empirically-
supported therapies...
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Page 16
There is Enormous Pressure
on Therapists-in-Training
Not only to diagnose, intervene,
and hel...
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Page 17
The Helping Profession, the Curing Profession
Therapists-in-training are burdened with
enormo...
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Page 18
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Empirical Research on Therapists‟ Self-Schemas
These are the therapist‟s cognitive,
emotional...
Powerpoint Templates
Page 20
Predominant Self-Schemas for Novice
Therapists
(1)Demanding Standards: “I have to cure all
my...
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Page 21
Predominant Self-Schemas for Experienced
Therapists
Experienced therapists also highly
endors...
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Page 22
The Intensity of the Psychotherapist‟s Ambition
Appealing to the “client” and “doing an
excel...
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Page 23
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The Imposition of Order and Certainty
A person coming for help, already in distress, is likel...
Powerpoint Templates
Page 25
What Ever Happened to the “Aha!” Moment?
There are few if any “aha
moments”!
“It is hard to d...
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Page 26
Duncan‟s Book “On Becoming a Better
Therapist”
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Page 27
A Long Tradition of the Clinical Utility of
Uncertainty
Jung‟s transcendent function: “within...
Powerpoint Templates
Page 28
A Long Tradition of the Clinical Utility of
Uncertainty
Winnicott‟s play space/transitional s...
Powerpoint Templates
Page 29
A Long Tradition of the Clinical Utility of
Uncertainty
Bion‟s (1962, 1970): “not knowing” an...
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Page 30
A Long Tradition of the Clinical Utility of
Uncertainty
Donnel Stern‟s important works ,“Unfo...
Powerpoint Templates
Page 31
Implications for Training and Supervision
1.) Current professional socialization seems to cen...
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Page 32
Implications for Training and Supervision
2.) One of the most challenging experiences for tra...
Powerpoint Templates
Page 33
Implications for Training and Supervision
3.) The trainee must become aware of his or her
“pa...
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Page 34
Implications for Training and Supervision
4.) Need to debunk the myth that there is a correct...
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Page 35
Implications for Training and Supervision
5.) Witnessing as a major therapeutic competency:
-...
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Page 36
Implications for Training and Supervision
5.) More on witnessing:
- Stern pays tribute to Har...
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Page 37
Implications for Training and Supervision
6.) Trainees must be encouraged to use their
subjec...
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Page 38
Conclusion
“In truth, we have all felt the burdens of
clients’ expectations that we fix their...
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Conclusion
“.... together with client’s expectations of
us, also restricts our sense of adven...
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Page 40
References
• APA Presidential Task Force on Evidence-Based
Practice (2006). Evidence-based pr...
Powerpoint Templates
Page 41
References
• Cook, D.C. (2013). A comparison of therapist schemas:
A quantitative study. Argo...
Powerpoint Templates
Page 42
References
• Hunsley, J. (2007). Addressing key challenges in
evidence-based practice in psyc...
Powerpoint Templates
Page 43
References
• Kose, G. (2003). Book review [Review of the book Between
conviction and uncertai...
Powerpoint Templates
Page 44
References
• Mollon, P. (1989). Anxiety, supervision and a space for
thinking: Some narcissis...
Powerpoint Templates
Page 45
References
• Stern, D. (1997). Unformulated experience: From
dissociation in psychoanalysis. ...
Powerpoint Templates
Page 46
References
• Wachtel, P. L. (2010). Beyond „ESTs‟: Problematic
assumptions in the pursuit of ...
Powerpoint Templates
Page 47
James Tobin, Ph.D.
Licensed Psychologist PSY 22074
220 Newport Center Drive, Suite 1
Newport ...
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Uncertainty, Being Uncertain, and Refusing Uncertainty: Can Therapists' Ambition in the Era of Evidence-Based Practice Be Counterproductive?

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In this paper presented at the Western Psychological Association 2013 annual conference in Reno, NV, James Tobin, Ph.D. cautions against the abandonment of uncertainty in the clinical encounter. He argues that in the current climate of evidence-based treatment, psychotherapists are internally and externally pressured to prematurely foreclose on potentially useful lines of inquiry and exploration.

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Uncertainty, Being Uncertain, and Refusing Uncertainty: Can Therapists' Ambition in the Era of Evidence-Based Practice Be Counterproductive?

  1. 1. Powerpoint Templates Page 1 Powerpoint Templates James Tobin, Ph.D. Licensed Psychologist PSY 22074 220 Newport Center Drive, Suite 1 Newport Beach, CA 92660 www.jamestobinphd.com 949-338-4388 Assistant Professor of Clinical Psychology, Argosy University 601 South Lewis Street Orange, CA 92868
  2. 2. Powerpoint Templates Page 2
  3. 3. Powerpoint Templates Page 3 “His mother is enmeshed with this boy and he needs to differentiate from her.”
  4. 4. Powerpoint Templates Page 4 “The violin is a surrogate sibling for the boy that he must give up in order to mourn the death of his sister.”
  5. 5. Powerpoint Templates Page 5 “The father’s abandonment probably left the boy with ambivalence about his own masculinity. The boy has chosen an activity that is feminine in order to punish both parents and as a way to protest his father’s philandering.”
  6. 6. Powerpoint Templates Page 6 “Why can’t he do both? Go to college then in the summers go to Europe for his musical training?”
  7. 7. Powerpoint Templates Page 7 I Thought our Field Aspired to Avoid Premature Conclusions or Erroneous Assumptions? Perhaps in the abstract .... but, unfortunately, it is not that way in reality (at least in my experience)! The ubiquitous nature of “frozen constructions of meaning” (Young-Eisendrath, 1997, p. 648) in many academic, clinical, and training contexts.
  8. 8. Powerpoint Templates Page 8 Nietzche Nietzche (1873/1999, as cited in Kose, 2003, p. 214): “ ... all knowledge is „nothing but working with favorite metaphors.‟ ”
  9. 9. Powerpoint Templates Page 9 “Instrumental Fictions” In Between Conviction and Uncertainty: Philosophical Guidelines for Practicing Psychotherapists, Downing (2000) argued that clinicians are guided by a personal epistemology: organizing schemas that serve as a heuristic for understanding patients. In his review of Downing‟s book, Kose (2003) called these heuristics “instrumental fictions,” [which are] “motivated by the conviction or desire to know the truth and provide useful illusions that allow us to work toward the fulfillment of that desire” (my italics, p. 214).
  10. 10. Powerpoint Templates Page 10 Knowing So We Don‟t Have to Think “A lot of us use (or misuse) theories, articles we have read so that we do not have to think about what the patient is communicating” (Witenberg, 1979, p. 277). ..... or have to get the patient to think about what he or she is saying (psychotherapy being a venue for self- relatedness is not really discussed!)
  11. 11. Powerpoint Templates Page 11 The Reduction of Uncertainty is a Neurocognitive Certainty There is a burgeoning literature on the neurophysiology and cognitive science of uncertainty that centers on the role of emotion in information processing (e.g., Baas, de Dreu, & Nijstad, 2012; Hirsh, Mar, & Peterson, 2012).
  12. 12. Powerpoint Templates Page 12 The Need to Reduce Uncertainty: Anxiety (1) Anxiety emerges when there is a mismatch between predicted and actual sensory events: “.. there is a massive increase in entropy as the individual‟s well-delineated plan of action gives way to uncertainty about the best way to construe the situation ... ” (Hirsch, Mar, & Peterson, 2012, p. 309).
  13. 13. Powerpoint Templates Page 13 The Need to Reduce Uncertainty: Structured Thinking (2) Emotions associated with appraisals of uncertainty lead to more structured thinking and ideation (Baas et al., 2012) and “[a]ttempts to minimize short-term entropy at all costs through the adoption of rigid cognitive structures and behavioral patterns” (Hirsh et al., 2012, p. 314).
  14. 14. Powerpoint Templates Page 14 The Need to Reduce Uncertainty: Dogmatism (3) ... “by willfully ignoring information that contradicts one‟s worldview or refusing to explore ... may in fact result in long-term adaptive failure despite the short-term reduction in anxiety” (Hirsh et al., 2012, p. 314).
  15. 15. Powerpoint Templates Page 15 Evidence-Based Practice (EBP) Ours is an environment of EBP, empirically- supported therapies (EST), and managed care (APA Presidential Task Force, 2006; Hunsley, 2007). Symptom reduction and the use of ESTs has become “the standard of care.” If progress doesn‟t occur, something is wrong with the psychotherapist‟s abilities or the treatment provided or both (Wachtel, 2010).
  16. 16. Powerpoint Templates Page 16 There is Enormous Pressure on Therapists-in-Training Not only to diagnose, intervene, and help, but to cure (the “helping profession” has become “the curing profession”).
  17. 17. Powerpoint Templates Page 17 The Helping Profession, the Curing Profession Therapists-in-training are burdened with enormous expectations, many of which are misguided (see Misch‟s 2000 paper “Great Expectations: Mistaken Beliefs of Beginning Psychodynamic Psychotherapists”), and many of which come from unresolved historical issues re: treating/healing a pathological care giving figure (Miller, 1997). These characterological predispositions are activated in the current environment of ESTs.
  18. 18. Powerpoint Templates Page 18
  19. 19. Powerpoint Templates Page 19 Empirical Research on Therapists‟ Self-Schemas These are the therapist‟s cognitive, emotional, and behavioral reactions to patients which are conscious and accessible to the therapist (the analogue of counter transference in cognitive psychology). A recent dissertation project (Cook, 2013) I chaired sought to compare the self- schemas endorsed by novice vs. experienced therapists.
  20. 20. Powerpoint Templates Page 20 Predominant Self-Schemas for Novice Therapists (1)Demanding Standards: “I have to cure all my patients. I must always meet the highest standards. My patients should do an excellent job. We should never waste time.” (2) Abandonment: “If my patient is bothered with therapy, he or she might leave. It’s upsetting when patients terminate. I might end up with no patients.” (3) Helplessness: “I feel I don’t know what to do. I fear I’ll make mistakes. I wonder if I’m really competent. Sometimes I feel like giving up.”
  21. 21. Powerpoint Templates Page 21 Predominant Self-Schemas for Experienced Therapists Experienced therapists also highly endorsed the “Demanding Standards” and “Abandonment” self-schemas! The third most highly endorsed self-schema was not “Helplessness” but “Excessive Self- Sacrifice”: “I should meet my patient’s needs. I should make them feel better. The patients’ needs often take precedence over my needs. I sometimes believe that I would do almost anything to meet their needs.”
  22. 22. Powerpoint Templates Page 22 The Intensity of the Psychotherapist‟s Ambition Appealing to the “client” and “doing an excellent job”– therapists are intent upon helping the patient feel better and do better, sometimes to an extreme level of intensity. This is potentially a narcissistic position, i.e., both personally and professionally (it can be argued that the treatment is more about us and the field than about the patient).
  23. 23. Powerpoint Templates Page 23
  24. 24. Powerpoint Templates Page 24 The Imposition of Order and Certainty A person coming for help, already in distress, is likely to want to create order – an old order – in such a paradoxical environment. The analyst or therapist, in response to what the patient imposes, is just as likely to impose an old order, in the form of theory, expertise, authority and his or her own psychological complexes” (Young-Eisendrath, 1997, p. 642).
  25. 25. Powerpoint Templates Page 25 What Ever Happened to the “Aha!” Moment? There are few if any “aha moments”! “It is hard to discover something if you already know what it is that you are looking for and where it is” (Duncan, 2010, p. 155).
  26. 26. Powerpoint Templates Page 26 Duncan‟s Book “On Becoming a Better Therapist”
  27. 27. Powerpoint Templates Page 27 A Long Tradition of the Clinical Utility of Uncertainty Jung‟s transcendent function: “within the psychic space of the transcendent function, one is free to watch and wait, not compelled to assign meaning prematurely to images, affects, memories or actions …. [in order to make] the discovery of … a meaning that was not previously known” (Young-Eisendrath, 1997, p. 641).
  28. 28. Powerpoint Templates Page 28 A Long Tradition of the Clinical Utility of Uncertainty Winnicott‟s play space/transitional space. John Keats‟s famous letter which he wrote in 1817 to his brother about “negative capability” (i.e., the artist‟s capacity to sustain him- or herself in the course of uncertainty; art is not what is done but what one is able to tolerate or take in).
  29. 29. Powerpoint Templates Page 29 A Long Tradition of the Clinical Utility of Uncertainty Bion‟s (1962, 1970): “not knowing” and approaching the clinical situation without memory or desire, based on Keats‟ concept of negative capability.
  30. 30. Powerpoint Templates Page 30 A Long Tradition of the Clinical Utility of Uncertainty Donnel Stern‟s important works ,“Unformulated Experience: From Dissociation To Imagination in Psychoanalysis” (1997) and “Partners in Thought: Working with Unformulated Experience, Dissociation, and Enactment” (2009b) which describe his view of the mutually co-created discovery process in psychotherapy and psychoanalysis.
  31. 31. Powerpoint Templates Page 31 Implications for Training and Supervision 1.) Current professional socialization seems to center on being “expert,” “empirical,” and “objective.” - An over-emphasis on these values/skills creates significant pressure and the tendency to act on the patient. - Leads to a preponderance of false-self phenomena.
  32. 32. Powerpoint Templates Page 32 Implications for Training and Supervision 2.) One of the most challenging experiences for trainees is learning to tolerate ambiguity and uncertainty (Lakovics, 1976). - The supervisee must help build the trainee‟s capacity for not-knowing – a “prerequisite for creative discovery” (Klugman, 2003, p.665). - Supervision can be a “space for thinking” (Mollon, 1989) in addition to didactic learning.
  33. 33. Powerpoint Templates Page 33 Implications for Training and Supervision 3.) The trainee must become aware of his or her “patterns of organization” and “organizing principles” (Klugman, 2003, p. 666) (one‟s personal heuristic), and how these relate to intentionality in treatment (i.e., what is the pragmatic connection between therapeutic self-schemas and intervention tendencies for the supervisee?).
  34. 34. Powerpoint Templates Page 34 Implications for Training and Supervision 4.) Need to debunk the myth that there is a correct way of doing everything in psychotherapy (e.g., What do you say when a patient arrives to a session late?).
  35. 35. Powerpoint Templates Page 35 Implications for Training and Supervision 5.) Witnessing as a major therapeutic competency: - Stern (2009a) argued, “At the beginning of life, we need a witness to become a self” (p.701) and, “our witness is our partner in thought” (p. 707).
  36. 36. Powerpoint Templates Page 36 Implications for Training and Supervision 5.) More on witnessing: - Stern pays tribute to Harry Stack Sullivan who, according to Stern ,theorized that “we know ourselves reflected appraisals” (Stern, 2009b, p. 706). - This idea is akin to Suzanne Johnson‟s (2008) Emotionally-Focused Therapy (EFT) intervention of “heightening.” - I describe this to students and supervises as “editing the scene.”
  37. 37. Powerpoint Templates Page 37 Implications for Training and Supervision 6.) Trainees must be encouraged to use their subjective self-experience and to be, at times, spontaneous (e.g., “Did you tell your patient something about what you were thinking or feeling?” – the response is invariably, “No!”). -“You mean we can tell the patient what we really think?” (see Renik,1996, 1999)
  38. 38. Powerpoint Templates Page 38 Conclusion “In truth, we have all felt the burdens of clients’ expectations that we fix their problems …. Understandably, though, we adopt these therapeutic roles because that is how we’ve been trained, or we just don’t know what else to do. Our limited tolerance for uncertainty ....
  39. 39. Powerpoint Templates Page 39 Conclusion “.... together with client’s expectations of us, also restricts our sense of adventure and co-discovery, influencing us toward cookie-cutter practices and away from the great, beautiful, and largely unknown territory of a client’s path to change” (Duncan, 2010, p. 149).
  40. 40. Powerpoint Templates Page 40 References • APA Presidential Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. America Psychologist, 61, 271-285. • Baas, M., de Dreu, C., & Nijstad, B.A. (2012). Emotions that associate with uncertainty lead to structured ideation. Emotion, 12, 1004-1014. • Bion, W.R. (1962). Learning from experience. London: Heinemann. • Bion, W.R. (1970). Attention and interpretation. London: Tavistock.
  41. 41. Powerpoint Templates Page 41 References • Cook, D.C. (2013). A comparison of therapist schemas: A quantitative study. Argosy University, Orange County, CA. • Downing, J. N. (2000). Beyond conviction and uncertainty: Philosophical guidelines for practicing psychotherapists. Albany: State University of New York. • Duncan, B.L. (2010). On becoming a better therapist. Washington, D.C.: American Psychological Association. • Hirsh, J. B., Mar, R.A., & Peterson, J.B. (2012). Psychological entropy: A framework for understanding uncertainty-related anxiety. Psychological Review, 119, 304-320.
  42. 42. Powerpoint Templates Page 42 References • Hunsley, J. (2007). Addressing key challenges in evidence-based practice in psychology. Professional Psychology: Research and Practice, 38, 113-121. • Johnson, S. (2008). Emotionally focused couple therapy. In A.S. Gurman (Ed.), Clinical handbook of couple therapy (pp. 107-137). New York: The Guilford Press. • Klugman, D. (2003). The figuration of reality: Psychoanalysis, animism, and the „pathetic fallacy.‟ Psychoanalytic Psychology, 20, 660-676.
  43. 43. Powerpoint Templates Page 43 References • Kose, G. (2003). Book review [Review of the book Between conviction and uncertainty: Philosophical guidelines for practicing psychotherapists, by J. N. Downing]. Journal of Psychotherapy Integration, 13, 211-215. • Lakovics, M. (1976). Some problems in learning to do „good psychotherapy. The American Journal of Psychiatry, 133, 834-837. • Miller, A. (1997). The drama of the gifted child. The search for the true self. New York: Basic Books. • Misch, D.A. (2000). Great expectations: Mistaken beliefs of beginning psychodynamic psychotherapists. American Journal of Psychotherapy, 54, 172-203.
  44. 44. Powerpoint Templates Page 44 References • Mollon, P. (1989). Anxiety, supervision and a space for thinking: Some narcissistic perils for clinical psychologists in learning psychotherapy. British Journal of Medical Psychology, 62, 113-122. • Nietzsche, F. (1873/1999). On truth and lies in a non- moral sense. In D. Breazeale (Ed. & Trans.), Philosophy and truth: Selections from Nietzsche’s notebooks of the early 1870’s. Amherst, NY: Humanity Books. • Renik, O. (1996). The perils of neutrality. Psychoanalytic Quarterly, 65, 495-517. • Renik, O. (1999). Getting real in analysis. Journal of Analytical Psychology, 44, 167-187.
  45. 45. Powerpoint Templates Page 45 References • Stern, D. (1997). Unformulated experience: From dissociation in psychoanalysis. Hillsdale, N.J.: Analytic Press. • Stern, D. (2009a). Partners in thought: A clinical process theory of narrative. The Psychoanalytic Quarterly, 3, 701-731. • Stern, D. (2009b). Partners in thought: Working with unformulated experience, dissociation, and enactment. New York: Routledge.
  46. 46. Powerpoint Templates Page 46 References • Wachtel, P. L. (2010). Beyond „ESTs‟: Problematic assumptions in the pursuit of evidence-based practice. Psychoanalytic Psychology, 27, 251-272. • Witenberg, E.G. (1978). The inevitability of uncertainty. Journal of the American Academy of Psychoanalysis, 6, 275-279. • Young-Eisendrath, P. (1997). Jungian constructivism and the value of uncertainty. Journal of Analytic Psychology, 42, 637-652.
  47. 47. Powerpoint Templates Page 47 James Tobin, Ph.D. Licensed Psychologist PSY 22074 220 Newport Center Drive, Suite 1 Newport Beach, CA 92660 www.jamestobinphd.com 949-338-4388 Assistant Professor of Clinical Psychology, Argosy University 601 South Lewis Street Orange, CA 92868 For additional instruction contact

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