How do you manage patients who send hostile or overly frequent messages through online patient portals in outpatient psychiatry?

This is a complicated yet important topic that should consider boundaries, diagnosis, threat assessment, and termination.

Starting with boundaries, I think it is important for the clinician to establish the boundaries that they are comfortable with and share that information with the patient, all while being therapeutic. These boundaries can be discussed in a session/appointment and agreed upon. The clinician can check for understanding and agreement. This is a good practice at the beginning of ...

The optimal approach will vary with patient and context, but in general, I feel it’s best to discuss this directly with the patient. Oftentimes, people aren’t aware of what frequency is appropriate, so gentle education helps. If it doesn’t, this might be someone you do not wish to contribute with, if boundaries cannot be established.

As to hostile posts, I would bring this up, address the anger or reason for the hostile posts, and address it head-on.

Might consider suggesting that if they have a...

Fortunately, I haven't encountered this in my own practice (and I don't want to jinx myself). I would approach it as a clinical behavior. Safety is paramount, so first ensure the situation is secure for both physician and patient. Then assess context to determine whether this reflects personality structure, paranoia, or acute destabilization. Set very clear boundaries about appropriate portal use and redirect clinical issues to the session. We are not obligated to tolerate abusive or hostile com...