Confabulation: An Introduction for Marriage and Family Therapists

Confabulation occurs when an individual recalls a memory that is inaccurate without the intent to mislead, deceive, or lie. Confabulation sometimes occurs when there is a disturbance in a person’s ability to retrieve memories and to monitor recollections for accuracy. Confabulation can occur in various forms. A person can recall a memory that occurred 20 years ago, accurately, but believe that the events took place yesterday.  Alternatively, a confabulation may manifest in sensationalized fabrications of events that never took place. Complicating matters, confabulation may be exacerbated by a number of neurocognitive disorders and other psychological and medical conditions. As such, it is likely that professionals who diagnose and provide therapeutic services to individuals with neuropsychiatric disorders will encounter patients who confabulate. Due to the importance of memory within the mental health care setting, and since many processes within this setting rely on a client’s recollections and memory (e.g., assessment, treatment planning, content shared in therapy sessions, etc.), greater awareness of confabulation among marriage and family therapists is warranted.

Marriage and family therapists are advised to take some of the following key points into consideration when discussing the topic of confabulation:

Identifying Confabulation. Confabulation is a term that is surrounded by some confusion. This is not surprising given its multiple definitions, uncertain etiology, and its overlap with a wide range of neuropsychiatric disorders. In fact, confabulation can occur in individuals who have no identified cognitive or psychiatric disorders. Identifying confabulation can be confusing for clinicians since it is unlike many other medical or psychological conditions in which patients are aware of their symptoms. Although this may be a confusing, vague, or even an unfamiliar topic, confabulation plays an important role in the mental health system.

Possible Causes for Confabulation. Although the origins of confabulation are uncertain, be rooted in a range of psychological, neurological, and other medical conditions. In particular, neurological problems have been identified as a possible cause. Damage to the basal forebrain or frontal lobe (e.g., anterior communicating artery aneurysm) may increase the risk of confabulation. Some authors also link confabulation to impairments in executive function (e.g., impaired judgment and forward-thinking deficiencies, problem solving deficits, poor decision-making skills, etc.) as well as to problems with encoding and retrieving memories.

Populations Prone to Confabulate. Several neurocognitive and neuropsychiatric disorders such as Alzheimer’s disease (AD), fetal alcohol spectrum disorder (FASD), schizophrenia, traumatic- brain injury (TBI), and Wernicke-Korsakoff syndrome (WKS) can render someone more vulnerable to confabulation.  Individuals who are prone to suggestibility may also be at an elevated risk to confabulate.

Presentations of Confabulation. Confabulation can range from small changes or updates to memories of an actual event to the large-scale creation of an event that never took place. Typically, individuals remain confident in the veracity of the confabulated memories, even when confronted by contradictory evidence.

Inspirations for Confabulation. Inspirations for confabulation can be drawn from social media and social companions.  Someone with an overactive imagination, and who may be fantasy prone, gullible, and have a tendency to please others may also be at greater risk to confabulate.  Individuals who also have autobiographical (consists of memories of one’s own life experiences) and source monitoring (verification of knowledge) deficits, may demonstrate increased rates of confabulation compared to the average population.

Differentiating Confabulation from Lying and Malingering. Confabulation is the creation of false memories in the absence of intentional deception. The latter is important, since many may misinterpret confabulation as a malicious attempt to deceive, rather than viewing it as the product of neuropsychological or memory deficits. Whether it is distorted memories of an actual event or the creation of an imagined event, confabulation is not identical to lying or malingering.  A single interview cannot provide sufficient insight in order to determine the motivation behind a client’s statements.

Verbal vs. Behavioral Forms of Confabulation. Confabulation can be expressed verbally or through behavior.  Verbal confabulation occurs when someone articulates a false memory. In contrast, behavioral confabulation occurs when someone acts on their false memory.   To some, confabulations may appear so real that those experiencing them may have a high level of confidence in their accuracy. The individual might say that he or she had lunch with a particular friend yesterday, and may even describe details such as location and what they ate for lunch; however, when the friend is asked about the situation, he or she indicates that they have not had lunch with the individual in a year.  Real emotions pertaining to the event can be shown, even though the event never actually occurred (for example, anger at a nurse stealing their wallet, when, in fact, they had no wallet in the room to steal or sadness over the death of a son, when in fact, they never had a son).

Common Types of Confabulation. Two subtypes of confabulation exist: spontaneous confabulations and provoked confabulations. Spontaneous confabulations occur without an apparent cause and tend to be rare. In contrast, provoked confabulations occur in response to an external stimulus, such as questions from a person in a position of authority. Amnesia and dementia may also increase the likelihood of provoked confabulation.

Delusions vs. Confabulations. Similarities and differences exist between delusions and confabulations. A delusion is a fixed belief that is false, but firmly held despite all evidence to the contrary. Although confabulations can also be false beliefs based on memories, the main difference between delusions and confabulations is that delusions tend to involve the misinterpretation of perceptions or experiences. Delusions usually remain fixed and unchanging; however, the individual may still function normally and have traditional perceptions in other domains. For example, an individual may sense that his or her food appears different from normal and may develop the belief that someone is poisoning the food; however, the perception of other situations remains accurate. Delusions also tend to involve an alteration of lifestyle in order to accommodate the delusion. To stay with the example of the food: the individual, who believes that his/her food is being poisoned, would likely avoid eating food that they did not prepare themselves. Delusions also tend to have a consistent theme across time and can be persecutory or grandiose in nature. In contrast, confabulation involves memory retrieval deficits and these false memories tend to be more isolated and more variable. For example, an individual may confabulate having had eggs for breakfast when this actually did not occur, but this would usually not lead to an alteration of behavior.  This would probably also not be a consistent and repetitive theme and he or she would not necessarily maintain this thought each day. Some patients, however, may experience spontaneous confabulations that appear to be implausible and indistinguishable from delusions, suggesting an overlap between the two and a common pathophysiology. One could likely distinguish between the two by analyzing the individual’s statements and behavior over time, looking for consistencies in functioning, and examining if there is a consistent theme to the content of the individual’s statements.

False Memories. A confabulation is a false memory. Although with complicated origins, confabulation may be a complete fabrication, or the result of mixing memories from different events to form a new, yet false, memory. These false memories may have resulted from exaggerations of actual events, insertion of memories of one event into a different time or place, or they could be the creation of an entirely new memory, of an event that never occurred. In some cases, the confabulated memory may be so peculiar that only a corroborating witness, like a family member or friend, may be able to confirm the veracity of the memory.

Memory Confidence. The accuracy of memories does not increase as a function of confidence in one’s memories. This is an important point since people, including professionals such as marriage and family therapists, may be more likely to believe a memory is true if the person appears to have confidence in the memory. This issue is particularly problematic when confabulation comes into play and is not accurately identified as such.

Suggestibility. Individuals who experience confabulation may also be prone to suggestibility. Specifically, these individuals may be likely to adopt the statements or views of others when prompted by repeated questioning and negative feedback. This commonly occurs during police interrogations and questioning by attorneys during testimony. When confabulation occurs and suggestibility takes place, this can also impact the reliability of the assessment and the treatment planning process.

Importance of a Strong Support System. If an individual experiences confabulation, the presence of a strong support system is imperative to ensure the accurate communication of personal and health-related information. Reliance on a supportive group of collateral informants bears the potential to maximize the accuracy of information, which is especially important when making important life-altering decisions.

Detection Difficulties. Despite appearances of confidence and accuracy, individuals may confabulate entirely false memories of details or events. The recognition of this is further complicated by the fact that individuals with confabulation are unaware that they are confabulating. As such, the recognition of confabulation can be incredibly difficult for therapists.

Emotional Impact on the Family.  In applying a more systemic view, a key consideration in working with individuals who confabulate significantly is an understanding about how family members cope with the individual whose memories are inaccurate. This could potentially evoke many emotions such as anger, frustration, sadness, anxiety, and fear. It is important to let family members know that these are normal responses to dealing with someone with memory retrieval deficits. Not only do these family members need to know how to support their loved one with, but they also need to have an opportunity to process how they feel about their own emotions and reactions to the situation.  It is important for the family to be aware that confabulation does not occur intentionally.

Countertransference in the Therapist. Similarly to the manner in which confabulation impacts family members, it can be frustrating for therapists to cope with, as they do not know what to believe. It is important to recognize these feelings when they occur and keep in mind that confabulation is often associated with neurological impairment and work with these individuals can be tedious, repetitious, and often requires behavioral intervention.

How to Address Confabulation. It is vitally important to corroborate information provided by individuals who are potentially at risk for confabulation. This is particularly important when the client’s articulation of memories could have significant consequences. Seeking out collateral informants and records to confirm or disprove self-reported accounts will increase the accuracy of assessment and appropriateness of interventions, if and when this is important to the therapeutic process. Although gently offering corrections for misremembered information may be helpful, understanding that confabulation is not intentional, and there is no malice involved, will definitely be helpful in establishing a therapeutic relationship.  Other strategies professionals should consider when working with someone they suspect is confabulating includes teaching the patient self-monitoring and memory monitoring strategies, encouraging the use of a memory diary, asking questions in an open and slow paced format, and the use of developmentally appropriate language. If a client is high functioning, the content of confabulations may offer rich and interesting material and insights into the perceptions, views, and approaches of the individual. This, of course, can be useful as long as there are no real life consequences as a result of the confabulation.

Author Biographies:

Jerrod Brown, MA, MS, MS, MS, is the Treatment Director for Pathways Counseling Center, Inc. Pathways provides programs and services benefiting individuals impacted by mental illness and addictions. Jerrod is also the founder and CEO of the American Institute for the Advancement of Forensic Studies (AIAFS), and the Editor-in-Chief of Forensic Scholars Today (FST) and the Journal of Special Populations (JSP). Jerrod is currently in the dissertation phase of his doctorate degree program in psychology.

Laura Cooney-Koss, Psy.D. M.CJ. is a licensed Clinical Psychologist in Delaware and New Jersey and is the owner and Clinical Director of Forensic Associates of Delaware, LLC. Dr. Cooney-Koss and the clinicians in this practice specialize in conducting psychological evaluations for a variety of legal referral questions and providing training for the community and professionals on forensic clinical issues.

Deb Huntley, Ph.D. teaches in the Social and Behavioral Sciences department at Concordia University, St. Paul. She is a licensed psychologist and earned her doctorate in clinical psychology from the University of Houston. Her research and areas of professional interest include child and family issues, psychopathology, and forensic mental health. She is currently a member of the editorial review board for The Family Journal, Forensic Scholars Today, and the Journal of Special Populations.

Pamela Oberoi, MA, is the Director of Refugee and Immigrant Services and a psychotherapist at Pathways Counseling Center. She specializes in trauma, war trauma, and acculturation. She also conducts research in the field of culture, immigration, and psychology, as well as on other topics. Pamela has written and published several articles on various mental health topics, including confabulation. She is a consultant and trainer for refugee mental health, and for cross cultural work in mental health.