Ink-ling of Identity: Unraveling Tattoo Culture for Mental Health Counselors

Dec 5, 2024 | Volume 14 - Issue 3

Russ Curtis, Lisen C. Roberts, Paul Stonehouse, Melodie H. Frick

Tattoo art is one of the earliest forms of self-expression, but the advent of colonialism, and its accompanying religious convictions, halted the practice in many Indigenous lands and led to widespread bias against tattooed people—a bias maintained to the present. How might the counseling profession respond to this residual bias and intentionally invoke a cultural shift destigmatizing tattoos? Through an extensive literature review, this article provides a more comprehensive understanding of tattoo-related mental health correlates, biases, and theories that enhance the effectiveness of counseling and parallel trends in the counseling profession that emphasize sociocultural influences on wellness. As a result of this survey, the authors propose a new theory of tattoo motivation, the unencumbered self theory of tattoos, which advances existing tattoo theory and aligns with current counseling trends by postulating that tattoos symbolize the uniquely human desire to transcend norms and laws imposed by external influences.

Keywords: tattoo, bias, mental health, theory, counseling

Imagine you are the parent of a 13-year-old girl. While at a parent–teacher conference, you learn your daughter is struggling with disruptive behavior and angry outbursts during class. The teacher asks if you would support your daughter seeing the school counselor and adds that the counselor is in the school building and available to speak with parents. You approach the counselor’s office, gently knock, and are welcomed by a warm, feminine-presenting adult. As the counselor offers their hand to shake, you notice an entirely tattooed forearm, and as you greet their eyes, more ink is evident on their neck.

What feelings, assumptions, or concerns emerge as you put yourself in the place of the parent in the above vignette? Despite the recent popularization of tattoos, a bias remains. Current research indicates that nearly half of adults in the United States between the ages of 18–34 have at least one tattoo (Roggenkamp et al., 2017), and the tattoo business is one of the fastest-growing enterprises, producing over a billion dollars in annual revenue (Zuckerman, 2020). This trend in tattoo art transcends the United States and is evident throughout the world (Ernst et al., 2022; Khair, 2022; Roberts, 2016). Nevertheless, bias against tattooed people remains, and women and people of color receive the brunt of this discrimination (Baumann et al., 2016; Guéguen, 2013; Kaufmann & Armstrong, 2022; Khair, 2022; Roberts, 2016). Given this meteoric resurgence in tattoo art and the discrimination that clings to it, implications for counseling practice inevitably exist.

Professional questions relevant to the counseling practice include: Is there a relationship between a desire for a tattoo and mental health? What motivates a person to seek a tattoo? In what ways may a tattoo bias subconsciously shape a counselor’s interactions with a client? How might the counseling community communicate a spirit of inclusion to the tattooed? To address these questions, this article employs the following structure. First, we provide a context for this bias by briefly examining the history and cultural perspectives of tattoos. Second, to establish the importance of this issue, we empirically demonstrate the reality of tattoo bias. Third, with this history of bias in mind, we comb the literature for research that explores the relationship between mental health and tattoos. Fourth, these relationships offer a frame of reference for our survey of established tattoo motivation theories, to which we propose an additional theory, the unencumbered self theory of tattoos, and reveal its significance within a clinical setting via a case study. Fifth, before concluding the article, we demonstrate how our inquiry’s content might be applied by enumerating our argument’s implications for the counseling profession.

Historical and Cultural Perspectives of Tattoos

The word tattoo originates from the Samoan term tatau, meaning “to tap lines on the body.” The practice of tattooing is known to have existed as early as 7000 BC, as seen on Egyptian mummies (Rohith et al., 2020). Otzi the Ice Man, dating back to 3000 BC, was discovered in 1991 with tattoos on his arms and wrist that are thought to have been applied for therapeutic purposes, a potential precursor to acupuncture (Schmid, 2013). Prior to the colonization of Indigenous lands by European countries, many tribes practiced the art of tattoo to symbolize adulthood, tribal membership, and status (Dance, 2019; Thomas et al., 2005). However, with the emergence of European imperialism, colonizers taught Indigenous people that tattoos were an abomination, scripturally prohibited, and therefore immoral. For instance, in The Holy Bible (New International Version, 1978, Leviticus 19:28) and The Qur’an (2004, Surah 7:46), specific passages forbid marking the skin.

Despite these condemnations, the practice of tattooing was not eradicated. Many cultures continued their tattoo traditions, and modern culture has adopted new traditions, which are even now expanding throughout the world (Ernst et al., 2022; Khair, 2022; Roberts, 2016). Although there is much intergroup variability, cultural identity can influence the motivation for and type of preferred tattoo. In India, for instance, tattoos often depict unique patterns specific to different tribal regions in the country. Specifically, in urbanized Indian geographic areas, there is increasing integration of tribal pattern tattoos with Western-influenced designs (Rohith et al., 2020). In Samoan culture, men receive an intricate tattoo called a pe’a while women receive a malu, both to indicate maturity (Dance, 2019). Lest the cultural importance of Indigenous tattoos be doubted, their misappropriation has resulted in litigation, thereby challenging attorneys to consider the property rights of tattoo designs (Tan, 2013).

Profoundly relevant to counseling, tattoos are often representational and symbolize something of importance. In a recent qualitative study of tattooed Middle Eastern women, Khair (2022) discovered themes related to taking ownership of their bodies in a patriarchal society and symbolism of their strength and desire to break free of patriarchal rules and religious mandates. In the United States, a study of mixed-race Americans’ tattoos revealed the most common tattoo themes include animal images and text of personally meaningful messages (Sims, 2018). In yet another group, White supremacists often get swastikas, crossed hammers, Confederate flags, and embellished Celtic crosses (Southern Poverty Law Center, 2006). Similarly, in Czech Republic prisons, the skull tattoo is a symbol representing neo-Nazi extremism, which then informs prison officials of inmates potentially becoming radicalized (Vegrichtová, 2018).

Exploring the intersection of religion and tattoos, Morello’s (2021) qualitative analysis of 21 people in three South American cities revealed that tattoos were more accepted among Catholics than evangelicals. Explained below, Morello classified the types of Christian tattoos as reversal, devotional, foundational, and then a nonreligious fourth category termed relational. According to participants, reversal tattoos symbolized regaining control of disempowering events, such as when Christians historically tattooed themselves to show Roman enslavers their devotion to Christ. Devotional tattoos were comprised of images and symbols representing religious themes (e.g., a cross), often used as a source of strength and identity. Foundational tattoos represent significant moments in life, such as major life transitions (e.g., the date of one’s conversion) or mystical experiences. Morello’s last category is akin to devotional tattoos, but the relational category was created to represent devotion to loved ones, such as images or symbols of one’s children.

In a related study examining the beliefs of religious women with and without tattoos, Morello et al. (2021) identified several common themes. This mixed methods study of 48 women in a conservative Christian college indicated that tattoos were not considered taboo by their religious friends and family and that tattooed participants spent considerable time determining which tattoo to receive. Predominant reasons for obtaining tattoos included social justice, friendship, and spiritual values. Summarizing previous research, individuals primarily choose tattoos to express their identity and uniqueness or to take ownership of their bodies. However, as discussed in the following section, there exists a bias against tattooed individuals.

Tattoo Bias

Unfortunately, with any practice that diverges from dominant cultural values, there is bias (Broussard & Harton, 2018). Although evidence indicates less discrimination against tattoos in the 21st century, negative judgments still exist explicitly and implicitly (Broussard & Harton, 2018; Williams et al., 2014; Zestcott et al., 2018). For example, Kaufmann and Armstrong (2022) found that law enforcement and the medical community hold negative sentiments toward tattooed people. They found that medical professionals who expressed negative judgments about their tattooed patients were likely to have patients not return. In fact, patients reported better rapport and increased trust with medical professionals who asked about the meaning of their tattoos. In other words, negative judgment toward, and lack of acknowledgment of, tattoos were detrimental to building the trust needed to provide optimal and consistent care (Kaufmann & Armstrong, 2022).

Unjustly, women and people of color with tattoos experience more significant discrimination than men or White people (Baumann et al., 2016; Camacho & Brown, 2018; Guégen, 2013; Solanke, 2017). For example, women encounter prejudice when failing to gain employment due to having visible tattoos regardless of having excellent job qualifications (Al-Twal & Abuhassan, 2024; Henle et al., 2022). Moreover, women of color have experienced job discrimination by being questioned if they have visible or nonvisible tattoos (i.e., inkism), being forbidden from having or being required to cover tattoos regardless of cultural relevance (e.g., covering a traditional Māori tattoo), or being required to prove that they do not have tattoos—as alleged in a legal complaint against a Singaporean airline that required female attendants to wear a swimsuit and demonstrate to their employers that they did not have tattoos (Solanke, 2017, Chapter 8). Women with tattoos also experience ambivalent sexism due to rejecting the feminine apologetic (i.e., not acting or dressing in stereotypical feminine ways); they are also perceived as wanting attention and sexually promiscuous (Heckerl, 2021). For instance, Guéguen (2013) found that women on the beach displaying a lower-back butterfly tattoo were significantly more likely to be approached by men compared to women without the tattoo, and the men interviewed indicated that they thought they had a better chance of getting a date and having sex with the tattooed women than the nontattooed women (Guéguen, 2013). In other words, men in this study had the biased perception that women with tattoos were more sexually promiscuous than nontattooed women.

This bias appears within incarceration rates as well. In a study conducted by Camacho and Brown (2018), they found that arrestees with neck tattoos were more likely to receive felony charges specifically for larceny offenses. Among these groups, Black individuals with neck tattoos were more likely than others to face felony charges (Camacho & Brown, 2018). It is also noteworthy that law enforcement catalog the tattoos of arrestees in the Registry of Distinct Marks (Miranda, 2020), which is kept in their permanent record and could potentially bias future incarceration and convictions due to the criminogenic stigmatization of individuals with tattoos (Martone, 2023; Rima et al., 2023).

Neck tattoos specifically appear to elicit bias (Baumann et al., 2016). Given two sets of photos of male and female faces, with a neck tattoo and without a visible tattoo, participants were asked to choose among the photos that they would most like to have as their surgeon. In a separate condition, participants were asked to choose who they would most like to have as their car mechanic. In both experiments, participants preferred to have a nontattooed person as their surgeon or mechanic. However, the preference was more substantial for a nontattooed surgeon than a nontattooed mechanic. Female participants assessed the tattooed faces more positively than male participants, but still preferred the nontattooed faces (Baumann et al., 2016).

Roberts (2016) suggested that although tattoos are becoming more prevalent worldwide, they are not yet entirely accepted. As such, employment discrimination occurs for people with visible tattoos. Roberts (2016) suggested employers discriminate primarily because of the fear of customer complaints and the concomitant loss of business. They further suggested that small businesses in rural areas, which tend to be more conservative, may be even more likely to refuse employment to tattooed workers.

Clients’ Perception of Tattooed Counselors
     To date, very few published studies examine the perceptions of tattoos within the mental health professional arena. One exception, however, is a recent publication examining the perception of potential mental health clients of psychologists with or without tattoos. Zidenberg et al. (2022) recruited 534 participants to determine if there were negative perceptions of psychologists who had tattoos. First, participants were presented with a mock profile of a fictional clinical psychologist. Each participant was randomly assigned to view one of three images of the psychologist: with no tattoo, a neutral tattoo (a flower), or a provocative tattoo (a skull with flames). Participants then rated the counselor on perceived competence and their personal feelings toward her.

Contrary to the researchers’ initial expectations, the psychologist’s photo with the provocative tattoo was rated more likable, interesting, and confident and less lazy than the psychologist with a neutral or no tattoo. Interestingly, the psychologist’s photo without a tattoo was rated as more professional, but this did not equate to participants’ believing that the psychologist would thus provide better care. The researchers speculated that while nontattooed people are viewed as more professional, they are not necessarily who clients believe will give the best mental health care. They further hypothesized that professionalism may convey a bias of being “better than” the clients and thereby might be perceived as less authentic. Moreover, participants in this study believed they would get better help from a more “authentic” psychologist, and that the provocative tattoo communicated a sense of authenticity (Zidenberg et al., 2022).

Mental Health and Tattoos
     Although early studies (e.g., Grumet, 1983) concluded that tattoos were a sign of maladjustment, contemporary research indicates that tattooed people are as healthy as nontattooed people (Mortensen et al., 2019; Pajor et al., 2015). In general, today the mere presence of a tattoo is not correlated with mental or behavioral issues (Roggenkamp et al., 2017). In fact, most people in many cultures conscientiously obtain tattoos to express themselves and honor people and causes they deeply care about (Khair, 2022; Naudé et al., 2019; Shuaib, 2020). Nevertheless, in one study of a German community (N = 1,060), which sampled people aged 14–44, 40.6% who reported childhood abuse or neglect had at least one tattoo, compared to 29.4% tattooed participants who reported no significant abuse (Ernst et al., 2022). However, Ernst et al. (2022) cautioned that the mere presence of a tattoo is not perfectly correlated with childhood abuse. Aesthetic embellishment of the body is the most common reason for getting tattoos, and it should not be considered an automatic indication of childhood abuse (Ernst et al., 2022).

Evidence suggests that the number of tattoos as well as their placement and content better indicate potential maladjustment than the mere presence of an easily concealed tattoo. Specifically, Mortensen et al. (2019) found that participants (N = 2008 adults) who had four or more tattoos were 15.4% more likely to report having been diagnosed with a mental health problem compared to 5.8% of participants with only one tattoo. Further, 13.4% of the participants with visible tattoos reported having a mental health diagnosis, and 28.2% of the participants who self-reported having an offensive tattoo also reported having a mental health diagnosis. In other words, multiple and visible tattoos may be more closely correlated with mental and behavioral issues than the mere presence of tattoos. However, contrary to Mortensen et al. (2019), in their study of life satisfaction with a sample of 449 participants (16–58 years old), Pajor et al. (2015) used the Multidimensional Self-Esteem Inventory (MSEI; O’Brien & Epstein, 1988), a psychological assessment tool with 116 items graded on a 5-point scale and designed to measure various aspects of self-esteem. Results indicated that tattooed people reported significantly higher competence than nontattooed: 37.2 versus 33.6 (p < .001). Tattooed participants also scored significantly higher on a measure of personal power, 35.6 versus 33.5 (p < .01), and significantly lower scores on a measure of anxiety and insomnia, 1.50 versus 1.75 (p < .05). Thus, although numerous visible tattoos could potentially indicate mental or behavioral issues, the research is not conclusive, suggesting the need for counselors to open-mindedly assess each client’s motivations for obtaining tattoos.

Contrary to previous hypotheses, tattoos are rarely a form of self-harm (i.e., cutting, self-mutilation). For example, Aizenman and Jensen (2007) analyzed a sample of college students (N = 1,330; ages 17–39) to determine mental health differences between students who self-injure and those with tattoos. The majority of tattooed students reported receiving tattoos as a way to express their individuality, while students who self-injured were motivated by feelings of insecurity and loss of control. Participants also completed assessments measuring depression and self-esteem. In terms of general wellness, the self-injury group (no tattoos) reported higher mean depression scores compared to both the tattoo group’s score and the nontattooed (no self-injury) score. The self-injury group also reported lower mean self-esteem scores compared to both the tattooed and the nontattooed groups. Noteworthy is the fact that there was no significant difference between the tattooed and nontattooed groups in terms of depression and self-esteem, which further suggests that tattooed college students are no more likely to experience mental health issues than nontattooed college students.

In a more recent study to determine whether tattooing was a form of self-injury, Solís-Bravo et al. (2019) found that from a sample of 438 adolescent males, 11.5% reported engaging in nonsuicidal self-injury (NSSI), but only 1.8% indicated receiving a tattoo with the explicit intention of feeling pain. However, they also found that 62.5% of the students with tattoos self-injured compared to 10.6% of students without tattoos. Thus, with this small subsample of tattooed NSSI students, it was suggested that tattooed adolescents should be screened for potential mental health issues. Yet, considering that only eight students in this sample reported getting a tattoo to feel pain, further replication of this work is needed before confirming a conclusive relationship between tattoos and NSSI (Solís-Bravo et al., 2019).

Exploring the correlation between tattoos and premature mortality (e.g., violent death, drug overdose), Stephenson and Byard (2019) found that there was a trend for people with tattoos to die at a younger age and to experience an unnatural death compared to nontattooed people. However, these results were not statistically significant, indicating that there was no meaningful difference between age and cause of death between tattooed and nontattooed people.

More contemporary research examined the relationship between body image and tattoo acquisition (Jabłońska & Mirucka, 2023). Using a sample of 327 Polish tattooed women to examine a relationship between body image and tattoos, 45.26% reported acceptance of their appearance and a deep connection to their bodies. Researchers speculated that they received tattoos as a way to adorn their bodies and express their individuality. Another 36% reported an unstable body image, meaning they perceived both positive and negative aspects of their bodies. It was speculated that this group used tattoos to conceal perceived flaws. The remaining 18.65% held a negative body image. Although the majority of their sample held either positive or mixed body image estimations, the researchers’ speculation as to why subjects received tattoos makes it difficult to infer correlation between tattoos and well-being. Nevertheless, nearly half the sample reported appreciation for their bodies and a desire to accentuate their positive self-image with body art.

Relatedly, some trauma survivors get tattoos to symbolize what they experienced and how they have grown (Crompton et al., 2021). The semicolon is one example of this, indicating that while one life chapter may have been traumatic, that is not the end of the story. Using tattoos to navigate trauma is further supported by Kidron (2012), who noted that some descendants of Holocaust survivors replicated the number tattoo on their arms to illustrate the connection to their grandparent, redefining the tattoos from markers of trauma to markers of survival and expanding their interfamilial bond and cultural identity.

In summary, studies indicate that the mere presence of a tattoo is not significantly correlated with mental or behavioral issues. Counselors should avoid assuming that tattooed clients have mental health issues, even if multiple visible tattoos are sometimes linked with adverse health outcomes or behaviors. Because tattoos are so often attached to identity, body image, and important life events, counselors should thoroughly explore with clients why they obtained such tattoos and what they symbolize. In order to assist with such exploration, the next section identifies a number of recognized tattoo motivation theories.

Tattoo Motivation Theories

To determine effective strategies to reduce tattoo bias and counsel tattooed clients, it is important to understand the motivations and theoretical premises of why people get tattoos. This section describes recognized tattoo motivation theories. Recent findings in tattoo research cited within this article highlight the limitations of these theories and prompted us to propose our own, the unencumbered self theory of tattoos, which focuses on sociocultural influences. From this new perspective, we hope counselors will have a clearer understanding of the motivations behind getting a tattoo, which will in turn increase understanding of tattoo culture and what this implies about clients and counseling practice. To illustrate how these theoretical models might be of use in a clinical setting, in the subsequent section we provide a case study in which we discuss, compare, and contrast theories and exemplify the need for a new understanding of tattoo motivation.

Psychodynamic Theory of Tattoo
     The first hypothesis for tattooing is rooted in psychodynamic theory. This theory posits that tattoos are an outward manifestation of intrapersonal conflict or unresolved psychological concerns (Grumet, 1983; Karacaoglan, 2012; Lane, 2014). The belief is that permanent skin marking serves as a visible mnemonic that prompts a defense mechanism that helps alleviate the anxiety caused by conflict within the id, ego, and superego. In other words, the symbolism embodied within the marking of the skin iteratively releases blocked psychic energy, causing temporary relief from various difficult symptoms.

Psychodynamic theory is problematic because it fails to address the alternative motivations for getting tattoos, namely, the aforementioned social–cultural perspective. Moreover, Freud’s psychoanalytic approach is rooted in Western civilization’s understanding of internal processes and is therefore heavily influenced by a European, White, male perspective of psychic processes, thus ignoring the effects of oppression and inequality on personal identity, mental health, and behavior. As was indicated in the previous research review, and as we will see in subsequent sections, current tattoo research does not support the notion that tattoos are merely the result of unconscious conflict.

Human Canvas and Upping the Ante Theories of Tattoo
     Moving beyond the arguably deficit ideology of the psychodynamic theory of tattoos, Carmen et al. (2012) proposed two evolutionary theories of tattoo motivation that transcend obvious reasons like self-expression and group membership. The first theory, human canvas, argues that it is our innate longing to express the most authentic desires of our psyche through symbolic thought, originally on cave walls and later on our bodies. Their second theory, upping the ante, postulated that with increasing longevity and improved health care, the opportunities for attracting mates are more competitive, and people must devise new ways to stand out to attract mates, much like a peacock spreading its feathers.

The human canvas and upping the ante theories of tattoos are at least to some degree supported by current research (e.g., Wohlrab et al., 2007), and both theories advance our understanding of the motivation behind tattoos beyond psychodynamic theory. Indeed, people spend considerable time and thought choosing their tattoos for personal self-expression (Kaufmann & Armstrong, 2022) and to symbolize cultural traditions, sexual expression, and the love of art (Wohlrab et al., 2007). Although these theories advance tattoo theory, they fail to consider the even deeper meaning which suggests that tattoos are a way to regain bodily control and express displeasure with mandated values imposed by external influences. In essence, it is clear that tattoos are a form of self-expression, potentially to increase personal uniqueness and attractiveness, but this fails to explain what people are hoping to express. Thus, informed by contemporary tattoo research, we propose a new and expanded theory that attempts to explain the rationale behind tattoo acquisition through a wider societal lens.

The Unencumbered Self Theory of Tattoo
     The unencumbered self theory of tattoos advances existing tattoo theory and aligns with current counseling trends by postulating that tattoos symbolize the uniquely human desire to transcend norms and laws imposed by external influences such as imperialism. After an exhaustive review of the tattoo literature, it is evident that the motivation to reclaim personal power from oppressive systems is one reason some people get tattoos, and this motivation is not explicitly stated within existing theories. While most closely aligned with the human canvas theory, the unencumbered self theory of tattoos differs in one subtle but essential way. The human canvas theory postulates that tattoos are a general form of self-expression (e.g., hobbies, memorials, identity, individuality). At the same time, the unencumbered self theory of tattoos suggests that specific individuals acquire tattoos as a deliberate assertion of autonomy and a repudiation of arbitrary societal norms. Take, for example, a client of Cherokee heritage who gets a tattoo depicting Cherokee syllabary. The human canvas theory would hold that this tattoo is motivated by the client’s desire to identify with her cultural heritage. The unencumbered self theory of tattoos acknowledges her desire to identify with her cultural heritage, but this desire is motivated by the need to disengage from the oppressive systems that successfully squelched her people’s values for so long.

Evidence supporting the unencumbered self theory of tattoos includes cross-cultural studies examining motivations behind obtaining tattoos (Atkinson, 2002; Khair, 2022; Kloẞ, 2022). Atkinson (2002) reported that Canadian women wore tattoos to challenge societal definitions of femininity, and Khair (2022) found that Middle Eastern women obtained tattoos primarily to express their uniqueness and to indicate ownership of their bodies. Khair (2022) stated, “In fact, women of the Middle East have been struggling to obtain the freedom of their identity due to various restrictive reasons that relate to religion” (p. 3). This sentiment is further supported by Stein (2011) who stated, “My data suggest that—rather than seeing themselves as capitulating to market forces—people think of their decision to get tattoos as an exceptionally deep expression of personal identity, as well as a dramatic declaration of autonomy” (p. 128).

Additionally supporting the cultural motivations behind obtaining tattoos, Kloẞ (2022) identified Hindu women having tattoos that symbolize both oppression from and resistance to patriarchy, colonialism, and orthodox religious beliefs. Relatedly, Stein (2011) stated that the motivation behind tattoos is, at least in part, “a defiance of patriarchal authority” (p. 113). This desire to live unencumbered is also evidenced in research indicating that tattooed people are less likely to be members of religious groups (Laumann & Derick, 2006); are less likely to conform to societal norms, as evidenced by lower scores on personality assessments measuring agreeableness and conscientiousness (Tate & Shelton, 2008); and are considered more authentic and relatable (Zidenberg et al., 2022).

The unencumbered self theory of tattoos also coincides with current research and theoretical advancements in the counseling profession. Integrative approaches, such as narrative, relational, and art therapies, illustrate how tattoos can be used to externalize issues and emotions onto the body and promote self-expression by re-authoring life stories that are freeing and healing (Alter-Muri, 2020; Covington, 2015). Further, there is an increasing interest in Indigenous healing practices and the counseling profession’s embrace of a more collaborative and collective approach to health and wellness. To illustrate how the unencumbered self theory of tattoos advances tattoo theory and serves the counseling profession, we compare and contrast the existing theories in the following case study.

Case Study and Discussion

In this fictional case study, Sage is a 28-year-old, cisgender, queer, able-bodied female whose mother is Eastern Band Cherokee and whose father identifies as Mexican American. Sage upholds many traditional Cherokee customs and regularly attends tribal council meetings as well as powwows where she dances in traditional native attire. Sage has several visible tattoos on her arms and one on the back of her neck, all of which symbolize her Cherokee heritage. She presented to counseling with increasing depression after quitting drugs and alcohol for the past year and reports being unhappy in her job with no meaningful relationships. Sage’s counselor does not have tattoos and identifies as White, female, and a social justice advocate who knows very little about people with tattoos or Cherokee customs.

From the psychodynamic theory of tattoo (Grumet, 1983), Sage’s tattoos would be considered an expression of inner conflict and unmet needs, and the counselor would ask questions hoping to uncover unconscious beliefs that are causing her depression. In this case, the counselor may not even mention her tattoos, but instead view them from a deficit lens indicating a personal problem to resolve.

In both the human canvas and upping the ante evolutionary theories of tattoos (Carmen et al., 2012), Sage’s tattoos could indicate her desire to express her individuality and enhance her attractiveness. With this in mind, the counselor is likely to acknowledge her tattoos and ask about their meaning. However, both theories fail to recognize that Sage’s tattoos may signify deeper underlying issues related to potential oppression and inequality she feels because of her race, ethnicity, and gender.

From the unencumbered self theory of tattoos, Sage’s tattoos could reflect her motivational factors, feelings of alienation, and desire to align her authentic self and heritage. From this perspective, the counselor might explore whether she has experienced discrimination and how the impact of societal marginalization shaped her current sense of self. For example, the counselor may ask, “Have you ever experienced feelings of alienation or disconnect from others, and if so, how do you think your tattoos relate to those experiences?” Another counselor probe could be, “What emotions or thoughts come up when you think about the stories or meanings behind your tattoos?” In addition, the counselor may inquire into cultural healing traditions that help Sage reclaim her authenticity and realign her with her Indigenous heritage. In this instance, the counselor may ask, “Are specific cultural or familial traditions associated with your tattoos, and how do they contribute to your sense of authenticity?” or “Have your tattoos played a role in helping you reconnect with or reclaim aspects of your cultural identity?” Ultimately, through understanding the unencumbered self theory of tattoos, the counselor can better assist Sage by gaining deeper insight into her experiences, her motivations, and the significance of her tattoos within the context of her identity and mental health journey.

In summary, clients’ motivations for tattoos are complex and include explicit explanations, such as self-expression and identity, and potentially implicit motivations, such as increased attractiveness and autonomy. Based upon the tattoo motivation research, we believe the unencumbered self theory of tattoos provides a more comprehensive understanding of the reasons people get tattoos, which appears to be motivated by boldly proclaiming their desire for autonomy and not merely to enhance personal attractiveness. With these findings in mind, the subsequent section describes how counselors, and the counseling profession more broadly, can enhance counseling practice with tattooed clients.

Implications for Counseling

     Tattooed clients and counselors will become increasingly common, if not the norm. Consequently, there are clinical, professional, ethical, and societal considerations associated with the increasing popularity of tattoo art. This section addresses what counselors can do to adeptly navigate the increasing prevalence of tattoo culture and better serve their clients.

Counselors must reexamine their potential bias about tattooed clients and recognize that current research suggests they are not more likely to have mental and behavioral problems (e.g., Pajor et al., 2015). In fact, tattoos on a client might indicate their readiness for counseling by showing their strength and desire to break free of parental and societal expectations (e.g., Crompton et al., 2021). However, the number and placement of tattoos may better indicate potential mental health issues (Mortensen et al., 2019). With this in mind, asking clients about their tattoos early in the counseling relationship may help build rapport and provide potentially rich information about the client’s life story. Specifically, if the client’s tattoo is visible, it would be appropriate and possibly helpful to ask about it during intake (Kaufmann & Armstrong, 2022).

To foster genuine rapport and mitigate power imbalances in the therapeutic relationship, it is crucial for counselors to engage in self-reflection, cultivate cultural awareness and humility, and understand the potential cultural significance of tattoos (Day-Vines et al., 2018). Initiating conversations about clients’ tattoos early in counseling can be an effective strategy. Counselors might ask: “Tattoos often have special meanings or stories attached to them. What inspired you to get yours?” This approach demonstrates respect for the client’s personal and cultural narratives, promoting a more equitable and empathetic counseling environment. For instance, inquiring about a client’s neo-Nazi tattoos demonstrates the counselor’s desire to understand all aspects of the client. Despite the offensive nature of the tattoos, questioning could prompt the client to disclose personal experiences such as family addiction, abuse, poverty, insecurity, and fear of losing one’s identity in an increasingly multicultural society. These disclosures might not have emerged otherwise.

Counselors do not necessarily need to cover their tattoos, because they may help increase clients’ perception of the counselor’s relevance (Zidenberg et al., 2022). In fact, the counselor disclosing their tattoos may propel some clients to share more personally relevant information during sessions (Stein, 2011). Depending upon the client, a counselor with tattoos could broach the topic of how their tattoos symbolize their pursuit of authenticity in a society where the values of marginalized populations (e.g., women, non-White, LGBTQ) are too often not recognized, understood, or honored.

This example shows how a counselor could broach the topic of tattoos:

During our sessions, we have been exploring various aspects of identity and self-expression, which has led me to reflect on something personal I would like to share with you. As you may have noticed, I have some tattoos that hold particular significance. I have found that my tattoos remind me of essential experiences and values in my life. I share this with you because I believe it is vital for us to foster an environment of openness and authenticity in our therapeutic relationship. However, I want to emphasize that our sessions are about you and your journey. So, if you have any questions or concerns about my tattoos or anything else, please feel free to share them with me. I am here to create a safe and open space to discuss anything that comes up for you.

     Thus, the counselor’s tattoo narrative may offer the client freedom to explore repressed aspects of themselves, which, once discovered, may allow for more self-awareness and appreciation, ultimately resulting in better mental health. Counselors can also simply discuss their tattoos with clients who express curiosity or concern. This approach allows the counselor to provide context and meaning behind their tattoos, potentially fostering a deeper connection and understanding between counselor and client.

However, some clients might be disinclined to continue services with an obviously tattooed counselor. As such, counselors may choose to cover their tattoos during sessions, especially if they anticipate that it may distract or discomfort certain clients. This approach can help maintain a professional appearance and minimize potential barriers to therapy. These kinds of tensions may lead to the strategic use of profile photographs on one’s counseling practice’s website. Depending on their client base and target demographics, counselors may opt for photographs that either prominently display or discreetly conceal their tattoos. Prioritizing the client’s comfort and preferences is essential. Counselors should gauge the client’s reactions and adjust their approach accordingly. In sum, the best advice for counselors with tattoos is to rely on their clinical intuition and discretion when deciding how to approach discussions about personal tattoos with clients. As with any counselor disclosure, discussing personal tattoos should be used intentionally with the client’s best interest in mind.

If a client inquires about the advisability of getting tattoos, it is essential to assist them in thoroughly processing this decision, as with any significant life choice. Be open with clients that biases against tattoos persist, with people of color and women being the most stigmatized. Regrettably, many individuals harbor negative perceptions of tattooed people, particularly regarding visible body art and content that might be deemed offensive. Counselors can ask probing questions about the client’s reasoning for obtaining tattoos, such as, “What does getting this tattoo mean to you, and how do you think it will impact your sense of identity or self-expression?” and “Have you considered any potential long-term implications of getting this tattoo, including how you might feel about it in the future or how it might affect your personal or professional life?”

The intersection of tattoos, mental health, and social justice represents a rich and largely unexplored area of research for counselor educators. As the prevalence of tattoos increases among both clients and counselors, we believe this presents a rich opportunity for personal exploration and the discovery of values and strengths, an area currently underexplored in the counseling profession. Future research on tattoos could examine their presence on counselors and clients, their effect on the therapeutic alliance, personality differences among tattooed individuals, and tattooed people’s likelihood of engaging in advocacy work. To advance dialogue and research in this domain, the Western Carolina University counseling program’s faculty, students, and graduates created the Intersection: Art, Mental Health, and Social Justice magazine (Mock et al., 2021). This publication aimed to enhance dialogue and understanding regarding tattoos. Readers are encouraged to peruse the online magazine to explore personal stories of tattooed counselors.

Conclusion

With the increasing popularity and prevalence of tattoos combined with continued cultural bias, body art is an area that warrants further research and discussion in the counseling profession. In summary, there does not appear to be significant relationship between tattooed people experiencing more mental health problems than nontattooed people. However, there is continued bias against tattooed people, and the reasons for obtaining tattoos are rooted more deeply than merely increasing personal attractiveness. As described in the unencumbered self theory of tattoos, the reemergence of tattoo art may be emblematic of the trends seen throughout the counseling profession to advance the discipline from its focus on intra- and interpersonal theories of health and wellness to include broader sociological perspectives on healing. The reemergence of tattoo art, then, could be an allegory for moving beyond the White, male, heteronormative standards that have traditionally dominated the profession, ushering forth an age of inclusivity where the rich and complex tapestry of all people’s values, traditions, and customs can be known and honored.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

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Russ Curtis, PhD, LCMHC, is a professor at Western Carolina University. Lisen C. Roberts, PhD, is an associate professor at Western Carolina University. Paul Stonehouse, PhD, is an assistant professor at Western Carolina University. Melodie H. Frick, PhD, NCC, ACS, LPC-S, is a professor at Western Carolina University. Correspondence may be addressed to Russ Curtis, Western Carolina University, 28 Schenck Parkway, Office 214, Asheville, NC 28803, curtis@wcu.edu.