Counseling Today, Member Insights

A beginner’s guide to client confabulation

By Jerrod Brown and Megan N. Carter September 15, 2020

In the context of mental health treatment, client confabulation refers to the unintentional recollection and formation of false memories, ranging from subtle embellishments to grandiose elaborations. Confabulation may take the form of a true memory being inserted into an incorrect temporal, spatial or event context. In other words, confabulated memories can be based on an actual memory taken out of temporal context, or they can result from the creation of a completely fabricated memory (one not based on a previously held belief, experienced event or memory). Confabulation may also involve the incorporation of confabulated details or events as part of a true memory.

It is important for mental health professionals to remember that people who confabulate are unaware that they are engaging in this memory phenomenon and have no intent to deceive. Clients who confabulate have no conscious awareness that their memory is false; in fact, they often strongly believe that their memory is true. Confabulation can also manifest in verbal or behavioral displays of unintentional dishonesty.

Confabulation is distinct from delusions, which are firmly held false beliefs that follow a consistent theme and result from psychosis, often involving an alteration of lifestyle to accommodate the false beliefs. It is also distinct from malingering, the purposeful deviation from the truth to achieve a desired outcome (e.g., reporting mental health symptoms that are not present to receive disability payments). Although confabulations and delusions may share a common pathophysiology (i.e., they can present similarly), they are separate phenomena.

Confabulation is a complex and confusing topic with an uncertain etiology, and it remains under-investigated within the context of mental health treatment. It is loosely associated with a number of neurobehavioral/neurodevelopmental disorders (e.g., fetal alcohol spectrum disorder [FASD], intellectual disability) and neuropsychiatric (e.g., schizophrenia), neurocognitive (e.g., dementia, traumatic brain injury) and medical health conditions (e.g., Korsakoff’s syndrome, various brain diseases). Adding to this confusion is the fact that confabulation can also occur among individuals with no identified impairments, disorders or diseases when certain factors are present (e.g., memory confusion, an attempt to fill in a memory gap, high-pressure and stressful interviews).

Although the underlying brain processes associated with confabulation are currently unknown, possible causes have been suggested in the research literature. These include:

  • Attempt to preserve self-coherence
  • Attempt at self-enhancement
  • Competing memories varying in strength and emotional significance
  • Executive functioning deficits
  • Fast-paced and stressful interviewing approaches
  • Frontal lobe dysfunction
  • Guided imagery
  • Hypnosis
  • Impaired attentional control
  • Impulsivity
  • Memory encoding and retrieval deficits
  • Memory loss
  • The mistaking of imagined events for real ones
  • Overconfidence
  • Attempt to preserve a sense of self-identity and self-esteem
  • Reality-monitoring deficits
  • Repeated lines of questioning
  • Self-monitoring deficits
  • An eagerness to please (i.e., wants to demonstrate an ability to answer all the questions)

Most commonly observed in the retrieval of autobiographical memories, confabulations can include information inspired by peers, television, movies and social media. Inspirations for confabulation may also occur from overhearing conversations from other individuals (e.g., inpatient treatment settings, group treatment programs, sober support meetings).

Mental health professionals are often unaware of this topic and typically receive little to no training in the implications of confabulation on client populations. Because of its potential to compromise screening, assessment, treatment efforts, discharge planning and placement, confabulation is a crucial clinical phenomenon for mental health professionals to understand and address in practice.

Types of confabulation

There are two principal forms of confabulation: provoked and spontaneous. Provoked confabulations are incorrect responses to questions or situations in which a person feels compelled to respond. Examples of such situations include intake assessments, investigative interviews and testifying in court.

Research has established that the more stressful a situation is perceived to be, the more likely confabulation is to occur. This is why mental health professionals working in criminal justice or forensic mental health settings need to pay particular attention to a patient’s possibility of confabulation, which may lead to inaccurate diagnosis or symptom identification. Additionally, unintentionally misremembered information can derail the legal process if the person provides inaccurate eyewitness information, prematurely waives Miranda rights, provides false confessions to police or enters inaccurate testimony in court. In the worst-case scenario, it could even result in wrongful convictions.

Spontaneous confabulations are not linked to a particular cue. They range from misremembering insignificant information to generating fantastic and grandiose details. They are believed to result from a reality-monitoring deficit in the frontal lobe combined with organic amnesia. Spontaneous confabulations also differ from provoked confabulations in that most patients eventually stop engaging in the behavior.

Provoked and spontaneous confabulations can be expressed either verbally or through behavior. Verbal confabulation involves articulating a false memory, whereas behavioral confabulation involves acting on a false memory (e.g., going to the wrong home because the person believes it is where they live). Regardless of the form they take, false memories can evoke real emotions from clients, who may have a high level of confidence in the accuracy of their recall despite evidence to the contrary.

An example that one of us experienced occurred in the course of a forensic mental health interview with a woman who was subsequently diagnosed with Korsakoff’s syndrome. During the course of the evaluation, it was clear that she had significant difficulty developing new memories but was able to recall long-term historical memories (e.g., childhood autobiographical memories). She described recently babysitting a neighbor’s three preschool-age children, including fixing them snacks and letting them watch television. A report was made to child protective services because of the woman’s significant impairments and concerns about the safety of the young children in her care. A subsequent investigation concluded that the woman had not been left to babysit the neighbor’s young children; this was an apparently confabulated memory.

Screening and treatment

There are various theoretical models to explain confabulation. One implies a failure to suppress memory traces that were used in the past but that are no longer relevant to what the person is currently trying to remember. Another theory posits that the person simply failed to retrieve the relevant memory. Finally, another theory is that the person failed to locate the memory for that time and context and essentially inserted another memory in its place.

Numerous conditions can increase the likelihood of confabulation, including:

  • Dementia
  • Encephalitis
  • FASD
  • Frontal lobe tumors
  • Frontotemporal dementia
  • Herpes simplex encephalitis
  • Learning disabilities
  • Nicotinic acid deficiency
  • Korsakoff’s syndrome
  • Multiple sclerosis
  • Schizophrenia
  • Subarachnoid hemorrhage
  • Traumatic brain injury

Given that confabulation has an unclear etiology, multiple definitions, and statistical and clinical associations with a range of neurobehavioral, neurodevelopmental, neurocognitive and neuropsychiatric conditions, the use of a valid and reliable screening procedure is essential. This will help mental health professionals avoid inaccurate diagnoses and the development of ineffective treatment plans that could exacerbate underlying conditions. Screening areas for consideration during confabulation evaluations include:

  • Abstract and sequential thinking
  • Attention-deficit/hyperactivity disorder
  • Executive functioning
  • History of trauma
  • Sleep
  • Learning capabilities
  • Social skills
  • Memory
  • Receptive and expressive language
  • Sensory processing
  • Source monitoring
  • Suggestibility
  • Prenatal alcohol exposure

While confabulation can occur for a variety of reasons, early identification, support and monitoring are key. Possible screening tools that may be useful include the Nijmegen-Venray Confabulation List and the Confabulation Screen. Use of these tools may provide a beginning analysis for further exploration of this issue. If confabulation occurs but is thought to be due to an organic condition such as Alzheimer’s disease, dementia or FASD, referral for neurological testing is appropriate and can provide insight into which areas of the brain are most affected. This can assist in determining the best treatment approach given the individual’s particular areas of need.

Regarding treatment, specific intervention strategies have been found to be useful with clients or patients who confabulate. These strategies involve:

  • Avoiding confrontation
  • Avoiding leading questions
  • Avoiding sensory overload
  • Avoiding closed-ended questions
  • Using a slow-paced interview format
  • Using collateral sources to confirm self-report
  • Using developmentally appropriate language
  • Reassuring that it is acceptable not to know an answer
  • Checking for comprehension
  • Minimizing stress
  • Providing family/support-person education
  • Allowing for extra processing time
  • Allowing for long pauses and silence
  • Treating underlying mental health conditions
  • Treating underlying physiological conditions
  • Teaching memory diary use
  • Teaching reality-monitoring techniques
  • Teaching self-monitoring techniques

Establishing a therapeutic relationship with such clients requires acknowledgment that their misremembering is not intentional and that it lacks malice. This can be challenging for clinicians for several reasons: countertransference, frustration at not knowing whether a client’s documented previous diagnoses or symptoms are accurate, and an unconscious bias that assumes the recollection of inaccurate memories is the result of the client trying to gain something else (i.e., malingering) such as money or attempting to get out of trouble.

Clinicians should avoid minimizing what the client is reporting or prematurely assuming that the client is deliberately being noncompliant. In fact, clinicians should recognize that the content of confabulations may even provide useful information regarding the client’s perceptions and behavioral approaches. Additionally, as previously mentioned, the confabulated information may result in real emotions for the client that will need to be acknowledged and processed.

Clinicians must be sensitive to the fact that individuals who confabulate may inadvertently thwart treatment efforts because they lack recognition that their recalled memories are false. To both address this lack of insight and ensure the collection of valid and reliable assessments, clinicians should obtain collateral information to support or refute a client’s claims (especially when a false recollection could result in significant consequences). When clear evidence of confabulation is found, clinicians should appropriately document this in the client’s case file and consider this during the entire treatment process (e.g., intake, screening, treatment planning, discharge planning).

Adaptive functioning

Confabulation can affect a person’s ability to take care of oneself (e.g., personal hygiene, dressing, cooking), carry out activities of daily living (e.g., home cleaning, clothing care, financial management), and effectively maintain a social life (e.g., empathizing, reading nonverbal behavior, establishing a social group, engaging in effective communication). These adaptive functioning deficits can also lead to issues with filing forms to obtain government services (e.g., disability benefits, subsidized housing) and gaining access to medical records to ensure high-quality continuity of care, as well as an increased vulnerability to victimization. Hence, those who chronically confabulate may be less likely to be able to live independently and more likely to require a high level of support.

Therefore, clinicians working with individuals who confabulate should consider administering a “gold standard” adaptive behavior inventory to help guide and inform treatment planning. Among these inventories are the Scales of Independent Behavior-Revised, the Vineland Adaptive Behavior Scales Third Edition and the Diagnostic Adaptive Behavior Scale. Similarly, clinicians working with clients who exhibit significant deficits in adaptive functioning, particularly in higher-level skills such as money management, should be alert to possible confabulations.

Although using a standardized assessment to evaluate adaptive skills can be useful in treatment assessment and planning, clinicians should also be aware of certain disorders, such as FASD, in which confabulation may be common and in which standardized testing does not necessarily identify deficits. For example, those with FASD may be able to complete tasks of daily living such as grocery shopping or managing personal hygiene, but they may have poor judgment (and social judgment in particular) that is not measured on typical adaptive functioning scales. For instance, they may be tricked out of money by someone who is “friendly” to them and then have difficulty understanding or explaining the missing money, so they engage in confabulation to account for it.

In such instances, in addition to using standardized testing, clinicians should carefully assess using qualitative analysis of abilities and interactions. This may be particularly important for those with FASD with regard to social skills or other areas of functioning that are difficult to measure. Confabulation may be demonstrated as a way to present a more functional ability with regard to a wide range of adaptive abilities and may need to be addressed through careful clinical interventions.

If adaptive behavior deficits are found, it is the responsibility of the administering clinician to educate the client’s support systems (family, friends, education system) about the practical implications of these deficits. These support systems may need to be relied upon in cases of severe confabulation to ensure client safety and follow-through on the client’s daily life affairs such as attending appointments and medication compliance. Unfortunately, strong support systems can be less common among this client population. Family, friends and teachers may feel distrustful of the confabulating individual because of a misperception that he or she is willfully attempting to deceive them. Clinicians play an important role in intervening in such misperceptions by educating clients’ support systems on the unintentionality of the confabulations and explaining that they are the consequence of cognitive and neurological deficits.

Conclusion

Confabulation can be a serious obstacle in mental health professionals providing effective care and services. It can have a negative impact on intake, screening, assessment, treatment planning, medication/treatment compliance and discharge planning. For this reason, we urge clinicians to pursue self-study and continuing education training via in-person and online courses to expand their knowledge on this complex and multifaceted phenomenon. When a case of potential confabulation is identified, professionals should seek the guidance of recognized subject matter experts who routinely review key research findings on confabulation on at least a quarterly basis.

Finally, additional research is needed to continue establishing evidence-based screening and intervention procedures to identify individuals who may be at increased vulnerability for confabulation. Such screening procedures could be applied prior to clinical interviewing and in the treatment planning process to ensure that the information obtained is of higher fidelity. The use of such protocols would also familiarize users with the social and cognitive risk factors for confabulation, of which many mental health providers currently lack awareness. Through the adoption of such policies and procedures, the possible negative impact of confabulation can be minimized, appropriate intervention approaches can be implemented, and the likelihood of positive outcomes can be increased.

 

****

Jerrod Brown is an assistant professor, program director and lead developer for the master’s degree in human services with an emphasis in forensic behavioral health for Concordia University in St. Paul, Minnesota. He has also been employed with Pathways Counseling Center in St. Paul for the past 16 years. He is the founder and CEO of the American Institute for the Advancement of Forensic Studies and is editor-in-chief of Forensic Scholars Today. Contact him at jerrod01234brown@live.com.

Megan N. Carter is a board-certified forensic psychologist who practices in Washington state. Her career focus has been on forensic psychological evaluations in both civil and criminal court proceedings. She has also focused on providing education about fetal alcohol spectrum disorders to mental health professionals.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Leave a Reply

Your email address will not be published. Required fields are marked *