Tarasoff, Obsessive-Compulsive Disorder, and the Duty to Warn: Legal and Clinical Perspectives in 2025

Over 50 years ago, the California Supreme Court in Tarasoff v. Regents of University of California, 13 Cal 3d 177, 118 Cal Rptr 129, 130, 529 P2d 553, 554 (1974) (Tarasoff I), introduced the seminal Tarasoff doctrine. The doctrine holds that a mental health professional’s relationship with the patient extends to the victim, creating a duty to exercise reasonable care when aware that the patient intends to harm the victim. The Tarasoff duty to warn remains one of the most influential doctrines in the realm of mental health and medical malpractice law, continuing to profoundly impact clinical practice today.

In the half-century since the landmark Tarasoff decision, states have adopted divergent approaches regarding the scope of mental health professionals’ duty to protect third parties from patient harm. California, the jurisdiction where Tarasoff originated, codified an expansive “duty to protect.” Cal. Civ. Code § 43.92. In contrast, Connecticut requires disclosure only in circumstances involving imminent identifiable risk. Conn. Gen. Stat. § 52-146c(c)(3) (2024).

Meanwhile, as the psychiatric field evolves, it is marked by advancements such as telehealth, the application of machine-learning risk models, and significant empirical research developments regarding disorders such as obsessive-compulsive disorder (OCD). Legal frameworks are also undergoing transformations, particularly in malpractice jurisprudence. At the same time, about one in 40 adults has OCD or will develop it at some point in their lives, many experiencing violent or taboo intrusive thoughts, known more commonly as obsessions. These obsessions are ego-dystonic – unwanted and resisted – but to an uninformed listener, they may resemble a threat.

To professionals lacking clinical expertise with OCD, a statement such as, “I can’t stop imagining stabbing my partner,” may be erroneously perceived as a direct threat of imminent harm. Such misinterpretations create a profound legal and ethical dilemma for mental health professionals. On one hand, inadequate disclosure of perceived threats could expose clinicians to tort liability if patient violence subsequently occurs. On the other hand, excessive disclosure may constitute a breach of confidentiality, jeopardize the therapeutic alliance central to effective treatment, and exacerbate the social stigma associated with mental illness.

Currently, legal frameworks must be recalibrated to align Tarasoff duties with contemporary psychiatric science. Particularly within the context of OCD, statutes and judicial interpretations should acknowledge the fundamental distinctions between OCD-related obsessions and genuine threats of violence. Failing to incorporate such nuanced understanding risks placing clinicians in a perilous position, caught between the threat of legal liability and the imperative to maintain patient trust. Such an alignment is essential to fostering a legal environment that supports effective psychiatric treatment while safeguarding societal interests.

Tarasoff and Its Progeny

The landmark Tarasoff case (Tarasoff I) established that mental health professionals have a duty to warn identifiable potential victims of harm. In the aftermath, the California Supreme Court articulated a corresponding standard in Tarasoff v. Regents of Univ. of California. 17 Cal 3d 425,430, 131 Cal Rptr 14, 19, 551 P2d 334, 339 (1976) (Tarasoff II), expanding the duty to encompass both warning and protective measures, such as notifying law enforcement or initiating hospitalization, provided these measures are reasonable.

Tarasoff quickly became a cornerstone of psychiatric malpractice litigation. While California codified the duty, other states responded unevenly. Some adopted a mandatory duty by statute or judicial decision (e.g., New Jersey in McIntosh v. Milano, 168 NJ Super 466, 403 A. 2D 500 (Super Ct 1979). Others, including New York and Connecticut, enacted permissive frameworks allowing but not requiring disclosure. A minority, such as Texas, rejected the duty entirely. Today, the United States is divided into a patchwork of approaches.

This doctrinal backdrop frames the central problem under consideration here. Tarasoff presumes that threats disclosed represent a genuine intent to act. Yet in the context of OCD, violent or taboo thoughts are often ego-dystonic – the opposite of intent. The clinician who hears, “I can’t stop thinking about stabbing my spouse,” may in fact be treating a patient suffering from intrusive OCD obsessions rather than a dangerous individual. The law, however, often fails to account for this nuance. The consequence is a dangerous double bind: under-disclosure risks liability if violence occurs, while over-disclosure risks breaching confidentiality and harming patients unnecessarily.

The Clinical Complexity of OCD

Obsessive-Compulsive Disorder (OCD) affects up to 2.5 percent of the population yet remains among the most misunderstood psychiatric conditions. OCD is characterized by obsessions – intrusive, recurrent thoughts or impulses – and compulsions – repetitive behaviors or mental rituals designed to neutralize the anxiety those obsessions provoke. Patients often recognize that their fears are irrational yet feel powerless to resist the urge to perform compulsions.

Contrary to the common stereotype of OCD as just “excessive cleaning,” a significant group of patients experience intrusive thoughts involving violence, sexual violence, or harm. Known as “harm OCD,” these thoughts can include, for example, fear of hurting loved ones, running someone over with a vehicle, or pushing someone off a ledge. Such thoughts are ego-dystonic – the patient finds them horrifying, unwanted, and inconsistent with their values. OCD patients are no more predisposed to engaging in violent acts than the general population; in fact, they often exhibit less aggressive behavior owing to increased feelings of guilt and avoidance.

For clinicians and courts, however, these intrusive thoughts can appear indistinguishable from genuine homicidal or suicidal ideation. The patient expressing, “I keep picturing myself stabbing my spouse,” may be experiencing a violent obsession that is part of their disorder – but may not pose an actual threat. The critical diagnostic key is whether the thought is resisted, unwanted, and accompanied by compulsive rituals or avoidance. Failure to appreciate this distinction risks conflating obsession with intent.

The legal implications are profound, especially surrounding the 50th anniversary of Tarasoff. A psychiatrist who discloses a patient’s threatening thoughts risks violating confidentiality, improperly institutionalizing the patient, or damaging the patient’s reputation. Conversely, neglecting to intervene in cases of imminent violence may render the clinician liable. The challenge is to find a balance: to act decisively when risk is real and imminent but avoid overreacting when intrusive thoughts are typical OCD symptoms.

Nonetheless, there is a strong argument that OCD warrants special consideration under the Tarasoff doctrine. The doctrine presumes that when a patient communicates a violent thought, it signals potential action. With OCD, that presumption is inverted; the thought is usually a marker of distress, not intent. Unless clinicians and courts understand this distinction, the law risks punishing patients for their symptoms and placing providers in untenable malpractice traps.

Connecticut’s Variations

The Tarasoff duty to warn remains a fragmented legal doctrine in 2025, characterized by significant variations in statutory language, judicial interpretation, and the scope of liability across jurisdictions.

Connecticut’s duty is restrictive and strictly applied. Conn. Gen. Stat. § 52-146c(c)(3) permits disclosure only where there is a “…risk of imminent personal injury to the person or to other individuals….” Connecticut’s seminal case, Fraser v United States, 236 Conn 625, 674 A2d 811 [1996], presented the question of whether a psychotherapist has a duty to control a patient being treated on an outpatient basis to prevent harm to third persons. With guidance from the Tarasoff decision and its progeny, the court found that the duty to take action to prevent injury to a third person was limited to situations in which the specific harm alleged by a plaintiff was foreseeable to a defendant. The court stated: “We deem it equally appropriate to balance the interests of those injured by psychiatric outpatients against the interests of the mental health profession in honoring the confidentiality of the patient-therapist relationship.” Indeed, multiple cases involving health care providers have upheld the Fraser foreseeability test, that is, requiring an identifiable victim.

In a more recent decision, Ashworth v. Town of Branford, No. HHD CV 23-6175575-S, 2025 Conn. Super. LEXIS 44, at *1 (Super. Ct. Jan. 10, 2025), a case with facts analogous to Tarasoff and applying the analysis in Fraser and its progeny, the court held, on a motion to strike, that the matter sounded in medical malpractice and declined to extend a duty of care by the psychiatric facility to the victim.

Accordingly, the Connecticut standard protects OCD patients by filtering out intrusive thoughts lacking a plan or intent. In malpractice claims, Connecticut clinicians can persuasively argue that ego-dystonic obsessions, without imminent threat and foreseeability, do not meet the statutory test.

Conclusion

In conclusion, as the Tarasoff doctrine enters its sixth decade, the tension between protecting the public and preserving therapeutic confidentiality remains unresolved. Nowhere is this tension more pronounced than in the treatment of patients with obsessive-compulsive disorder. OCD demonstrates the fundamental flaw in assuming that all violent statements carry equal weight: Intrusive, ego-dystonic obsessions are qualitatively different from genuine threats. Yet the law’s blunt tools often fail to capture this distinction, leaving clinicians vulnerable to malpractice exposure whether they disclose too much or too little.

Meet the Author

Audrey D. Medd

Associate, Wilson Elser

Audrey D. Medd is a seasoned trial attorney with more than 20 years of experience representing various medical professionals in all aspects of medical malpractice defense litigation. She has extensive experience appearing before state and federal courts, bringing a wealth of insight and judicial perspective to each case she manages. Audrey effectively handles all phases of litigation from inception to trial, including thorough early assessment, pleadings, discovery, and the strategic use of motion practice to secure early resolution and favorable client outcomes.

Prior to joining Wilson Elser, Audrey worked for a prominent New York City firm. Previously, she gained valuable experience litigating matters spanning a diverse range of practice areas at several established firms in New York and Connecticut.