By Hannah Furfaro
The Seattle Times
SEATTLE — A patient was already tied to the bed, their ankles and wrists bound by thick Velcrostraps.
From behind, a mental health worker pulled a mesh hood over their head.
Another injected the young adult with medicine. A third gripped the hood, holding their neck tight against the mattress.
The patient’s lips, pressed against the mesh, sucked for air like a fish.
In less than two minutes, six staff at Recovery Place Kent, an inpatient psychiatric facility in a suburb south of Seattle, had wrested the patient into total submission by relying on a spit hood, a form of restraint many experts say should never be used on people being treated for mental illness.
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A Seattle Times investigation has found staff in medical settings across Washington and in at least 28 other states have used spit hoods over the past decade to subdue or control psychiatric patients and risk psychological distress, suffocation and even death in the process.
In other contexts, like law enforcement, these hoods have recently become more heavily regulated — especially after being linked in media reports and lawsuits to the deaths of dozens of mentally ill people in jails and police custody. This includes Manuel Ellis, who died in 2020 after Tacoma police hog-tied him face down and covered his head with a fabric spit hood that became caked with his mucus and blood.
A pervasive narrative is that if people like Ellis had received mental health care instead of arrest, they would not have died.
But medical systems, which are supposed to be safe harbors for people in need, are using them in potentially life-threatening ways with virtually no accountability or oversight.
The Seattle Times conducted a 50-state survey of agencies that oversee state-run psychiatric institutions, interviewed 14 health care professionals and reviewed hospital inspection reports, internal facility records, media coverage and lawsuits to uncover a previously unreported pattern of use that spans many states and types of medical settings.
They’re used inside facilities big and small, public and private.
On people so sick or drugged up they can’t remember what happened.
On children as young as 8 years old.
Over the past decade, the investigation found, at least five people receiving medical care in the U.S. have died as a result of incidents involving spit hoods.
Medical staff have hooded patients without physicians’ orders and in tandem with the most extreme forms of restraint, like binding their limbs to a bed and injecting them with sedatives against their will.
They’ve been used on people with serious heart problems.
And on people who’ve been sex trafficked.
“There’s no regulation, there’s no research, there’s no evidence to support their use,” said Dr. Tobias Wasser, former chief medical officer at Connecticut’s only maximum security psychiatric hospital. When leadership weighed using spit hoods years ago, they decided against it and stocked face shields for staff instead, he said. Spit hoods, they concluded, were unsanitary, unsafe and inhumane. “It’s insulting and dehumanizing, and I would never support the use of that device,” he said.
A former administrator at Valley Cities Behavioral Health Care, the nonprofit that operates Recovery Place Kent, couldn’t “think of much else that’s legal that you can do that is more dehumanizing than covering somebody’s entire head and face.”
“It makes me feel really ill,” said the former administrator, one of six current and former Valley Cities employees who spoke about the nonprofit on the condition of anonymity out of fear of retribution or lost employment.
If they’re used to restrict people’s heads, spit hoods — also known as spit socks, spit guards or spit masks — could fall within the scope of federal and state laws that govern restraints like ankle and wrist straps, some experts say. But unlike other types of restraints, spit hoods aren’t regulated by the U.S. Food and Drug Administration.
No regulation means no official government reporting.
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Without statistics, instances when people do get hurt look like one-offs, and are often chalked up to poor training, patients’ violence or underlying health conditions. Even some legal, patient-rights and medical professionals say they’re under the impression that spit hoods are rarely or never used on psychiatric patients.
But nationally, spit hoods have been used in a majority of states and are being used inside state-run psychiatric facilities in at least 15 of 29 states that responded to The Times’ survey, some of which have no written policy on when and how to use them.
And unlike use by police, where dash and bodycams have revealed their deadly potential, much of what goes on inside health care facilities is invisible to the public.
Inside a seclusion and restraint room at Recovery Place Kent, a twin-size bed is bolted to the ground. There are no windows to the outside. A camera surveils from the corner.
At facilities like this, some patients are such a safety risk that staff decide to restrain them.
Straps pin down their arms and legs.
Patients may fight back. Sometimes they spit.
That’s when staff might grab a spit hood.
“Everything’s happening so fast,” said a former Recovery Place Kent staff member who restrained patients, calling the experience “scary” and “traumatizing” for everyone involved. “The spit hoods,” the former employee said, “That was crazy to me.”
This is a place reserved for emergencies, where staff bring patients who are so distressed they’ve hurt or are at risk of hurting themselves or others. Usually what happens in rooms like this is shielded from public view, but an insider provided Valley Cities records to The Seattle Times that offered a unique glimpse inside.
Made from mesh and sometimes cloth, spit hoods were patented as an infectious disease-prevention device for law enforcement to use on suspects during arrests.
They fit into a long history of using hoods to subdue those seen as threatening or violent.
“If you put a hood over a horse, it immediately becomes docile,” said Christopher Frueh, a professor of psychology at the University of Hawaiʻi at Hilo who has researched patient trauma inside psychiatric units. “Terrorists, military, paramilitary units, put hoods over people they’re trying to control.”
If used according to the manufacturer’s instructions, a spit hood should fit loosely, and its wearer should be able to breathe and see normally.
But just as ankle and wrist straps have historically been misused and overapplied, spit hoods can be abused, experts say.
“As soon as you start using them, the use is not as tightly regulated as it should be or could be, and then they’re being used in situations where it’s not even indicated,” Wasser said. “It becomes a slippery slope.”
There’s no data on how many times these hoods have resulted in injuries or deaths within medical settings. But records reviewed by The Seattle Times identify use experts consider unsafe in settings ranging from ambulances to inpatient units to emergency rooms.
At Recovery Place Kent, records show staff have used spit hoods to pull at least three different patients’ heads into surrender.
In 2024, nine staffers there swarmed a patient struggling against their attempts to strap her down. She screamed, then spit, as one staffer knelt on top of the bed to get a better grip. Another employee used a mesh spit hood to hold the patient’s head to the mattress.
At a Kansas hospital in 2018, staff tied down a 13-year-old’s limbs, restrained her neck and put a hood over her head after she sought care following a suicide attempt and drug overdose, according to a federal inspection report.
Over the five days she spent in the hospital, the teen’s wrists and ankles were tied down for at least 55 consecutive hours as she continued to threaten to hurt herself; information about when the spit hood was removed, government inspectors noted, was missing from the patient’s records.
“On day two I was going to take the restraints off but she was being so mouthy,” a nurse told inspectors, who later noted in their investigation that staff restrained the teen “as a matter of retaliation.”
When the teen was finally discharged, her hands were swollen, she was weak and she could hardly walk, her guardian told inspectors.
“I just feel like they failed my girl,” he said.
In 2022, 47-year-old LaDamonyon “DeeDee” Hall was experiencing a mental health crisis when Dallas paramedics covered her head with a mesh spit mask. Hall repeatedly yelled “I’m dying,” coughed and struggled against handcuffs and a strap that bound her waist to a gurney.
When Hall eventually fell silent, a video from the encounter shows, a paramedic left her hooded and repeatedly asked her “what’s going on.” Several minutes passed before he began CPR.
Hall was declared dead at Baylor University Medical Center. The county medical examiner ruled her death an accident.
Patients are sometimes hooded even if they haven’t spit or are lucid enough to explicitly say they won’t.
In 2024 at Washington’s Western State Hospital, a patient being strapped to a restraint chair panicked when she saw the hood coming.
“I’m not spitting, I’m not spitting!” she cried, according to a patient abuse complaint filed by a hospital employee.
“I don’t believe you!” a licensed practical nurse allegedly said before forcing “the spit mask over (the patient’s) head/face … pulling it extremely tight around her neck.” The outcome of the complaint was not clear.
“I’m not allowed to comment directly on that particular case,” said Dr. Brian Waiblinger, chief medical officer at Washington’s Department of Social and Health Services. But “if a case like that did happen, the person in charge of the seclusion or restraint would direct them to stop that.”
Staff have hooded patients at Washington’s state psychiatric hospitals at least 149 times over the past eight years, according to a data search state officials completed this fall following a Seattle Times request; Washington doesn’t log spit hood use, so officials said they did a “cursory” search using keywords. Other large private mental health facilities in the area, including Fairfax and Smokey Point behavioral health hospitals, said they don’t use the hoods.
In 90% of the 34 incidents across the country documented by The Seattle Times, medical professionals used spit hoods in combination with other forms of restraint including sedatives, limb straps or handcuffs. Because of this and other circumstances, like patients’ underlying health problems, drug or medication use, it’s difficult to say definitively what role spit hoods play in injuries and deaths.
Some health care professionals say spit hoods pose unique risks.
“There’s a big difference between wrist and ankle restraints and neck restraint because, you know, the airway goes through your neck,” said Kathy Day, a retired nurse who advocates for patient safety through the Patient Safety Action Network. Over a few decades working in ERs in Maine, Day was spat on, bitten, choked and kicked by psychiatric patients. She said she completely understands “the need for protection for worker safety.” But “if they’re using that as a neck restraint, then that’s basically a choke hold.”
Some law enforcement agencies have recognized the risk in recent years: In Washington, a statewide policy limits police from using them on certain populations, like people who are struggling to breathe.
The biggest safety concern is suffocation, said Ed Budge, a Seattle -based attorney who secured several million dollars in two spit hood-related death and injury settlements involving police.
One heavy-duty option, called the TranZport Hood, has a fabric mouth covering that its maker touts for its impermeability. The hood successfully contains “the saliva and the blood” of its wearers, the brand’s website reads. And its instructions come with a grim warning: “Improper use may cause asphyxiation, suffocation or drowning in one’s own fluids.”
“They’re like any other tool, right? When they’re used properly, they can be helpful, and when they’re used improperly, can be super dangerous,” said Budge. “And when I say used improperly, the cases that we have dealt with have involved people who have been in an excited state, high heart rate, heavy breathing, for whatever reason.”
At Recovery Place Kent, patients sometimes kick, push or flail to escape the grip of staffers trying to restrain them.
Some are hallucinating or experiencing delusions.
Others scream and cry.
Once the hood goes on, whether it’s safe is usually an afterthought.
“Sadly,” a former staffer said, “We were more worried about … getting the restraints on.”
For decades, medical facilities used restraints like sedatives or ankle and wrist cuffs carte blanche.
That changed following news reports and a federal investigation in the late 1990s linking restraints to hundreds of injuries and deaths. The federal government, states and hospital accrediting agencies have since developed use standards, reporting rules and training requirements.
In practice, spit hoods have fallen outside the bounds of these mandates.
The U.S. Centers for Medicare & Medicaid Services, which enforces national health care safety standards, doesn’t require training for their use. Spit hoods aren’t mentioned in the American Psychiatric Association’s seclusion and restraint guidance and the association does not have a “formal position on spit hoods as a form of restraint” a spokesperson said. And The Joint Commission, a leading hospital accrediting agency, gives facilities discretion “to determine the appropriate use of spit guards or hoods.”
Several professional organizations, including the American Psychiatric Nurses Association, have written commitments to generally reducing restraint, but don’t reference spit hoods; The APNA and Washington State Nurses Association declined requests for comment.
Hospitals and psychiatric facilities are inconsistent in how they train staff to calm patients or physically restrain them. And instructions on how to use spit hoods are absent from leading health care training programs, like the Crisis Prevention Institute.
At Recovery Place Kent, where staff receive CPI training, decision-making inside restraint rooms was often “blurry” and “no one got proper training,” on spit hoods, said a former staffer. Valley Cities officials dispute this, saying that the organization uses internal spit hoods training and if staff aren’t trained they’re not allowed to use them.
Washington state law requires medical facilities to train certain staff in restraint practices within 90 days of their hiring date. In spring 2025, internal records show, 46% of the facility’s staff had expired or no crisis prevention training on file; Valley Cities officials said 23% still needed certification as of May and that those without it “are restricted from actively engaging” when patients are in crisis.
“You could potentially get hurt, obviously, and the client could potentially get hurt being under that spit hood,” a former staffer said. “Everyone needed and should have proper training on (spit hoods) if we were truly going to use it.”
Another former employee said, “The average nursing team there doesn’t receive any type of training on how to stabilize a (patient’s) head … everything they do is highly improvised.”
Facility leadership made efforts to make spit mask usage safer by reviewing videos of patients being restrained and, according to Valley Cities officials, tasking nursing and inpatient service leaders with writing a spit hood policy. But in the years that followed, internal records show, staff continued to hood patients in risky ways.
Spit hoods are used “to mitigate the possibility of infecting staff with infectious mucus, and to mitigate the negative reaction, inherent to being spit upon,” Richard Geiger, chief of inpatient and residential services at Valley Cities, said in an emailed response to a detailed list of incidents and other findings provided by The Times. “The use of a ‘spit hood’ as a restraining mechanism is never authorized or condoned.”
Standard crisis prevention trainings emphasize safety and teach health care workers to treat patients with dignity and care — wiping their brow or situating their glasses properly — when restraining them against their will.
These professional guidelines are at odds with how spit hoods are used in some settings, health care professionals told The Seattle Times.
Inside an Illinois emergency department in 2023, for instance, a hospital security officer punched a psychiatric patient in the face after “forcefully” putting a spit hood over their head, according to a hospital inspection report. The hood stayed on as another security staffer held their hand over the patient’s face.
“We strangled (the patient) down,” that staffer told government regulators, who imposed the most severe level of sanctions against the hospital following their inspection.
Neither security guard had undergone mandated training. And aside from firing one of the guards, according to the inspectors’ records, the hospital’s internal review resulted in no plans to prevent future abuse.
At least 11 of 15 states that use spit hoods inside their state-run psychiatric facilities say they consider spit hoods a restraint — placing them in the same category as straps used to hold down a patient’s arms and legs.
But they’re not treated as such by the federal and state agencies that have power to regulate them.
The U.S. Food and Drug Administration, for example, doesn’t classify spit hoods as a medical device, a distinction that could subject them to safety regulations. And although the U.S. Department of Health and Human Services requires hospitals to document restraint-related deaths, the agency doesn’t include spit hoods among its list of reportable devices.
Six states that responded to The Seattle Times survey said they have no statewide spit hood rules and instead leave decision-making up to individual state-run facilities.
You “need to have some kind of monitoring institution,” said Dr. Jeffrey Metzner, who called The Seattle Times’ findings “disturbing.” Metzner, clinical professor emeritus of psychiatry at the University of Colorado Anschutz School of Medicine, served on an American Psychiatric Association seclusion and restraint task force focused on correctional facilities.
In Washington, spit hoods meet the state’s legal definition of restraint and, according to state officials, they’re used at five of the state’s public psychiatric institutions.
But they’re mentioned only in passing — as a type of personal protective equipment, not a restraint — in training guidelines used at some of the state’s public facilities, part of a system of care that is funded by nearly $1 billion in taxpayer dollars and responsible for about 3,000 inpatients.
Western State Hospital has used spit masks for more than a decade, Waiblinger said. But the state has no overarching spit hood policy. Waiblinger said he started working on one in October 2025; once it rolls out, he said, the devices will formally be considered a restraint.
Although a handful of states say they record spit hood use in individual patient records, not a single state that responded to The Times’ survey systematically tracks and reports these incidents.
Without data, tracing systemic problems is virtually impossible.
“That, to me, is a red flag,” said Yanling Yu, co-founder and president of Washington Advocates for Patient Safety. Since spit hoods used in jails and by police “caused people harm or death, then they should at least have a close examination about what is the proper use in a health care setting.”
Academic researchers aren’t filling the gap.
Using spit hoods as a restraint “sits outside of the normal definitions,” said Dr. Daniel Whiting, clinical associate professor in forensic psychiatry at the University of Nottingham in England. Whiting and his colleagues recently examined restraint practices across 22 countries but he said “spit masks would have been outside the scope of that review because they’re not something that’s technically used to immobilize.”
There are tools to protect patients: Government regulators can shut down, fine or cut off funding to medical facilities, and some hospitals have banned spit hoods after facing severe penalties.
In 2023, for instance, federal regulators placed Rochester General Hospital in New York in “immediate jeopardy” — a serious violation that risked the hospital’s ability to be reimbursed by Medicaid and Medicare — after they discovered the hospital lacked spit hood policies. The hospital immediately banned spit hoods, boosted restraint training and agreed to audit patient records to ensure staff complied with the new rules.
But those tools aren’t used very often. The U.S. Centers for Medicare & Medicaid Services inspects the nation’s hospitals only once every three to five years.
In Washington, the nonprofit watchdog group Disability Rights Washington can legally show up unannounced and investigate abuse and neglect inside psychiatric facilities. Todd Carlisle, a DRW attorney, said he’d never “had any reason to” investigate the use of spit hoods before hearing about The Times’ findings. “I’m definitely going to start now.
The agency’s Treatment Facilities Program, though, has only three full-time staff responsible for monitoring and responding to complaints at dozens of psychiatric facilities across the state. “The need for more oversight is, I think, obvious,” he said.
Left on their own, patients have little opportunity for recourse.
At a psychiatric hospital in Alaska in 2016, medical staff who hooded a 14-year-old continued caring for the teen for weeks after hospital leadership found the incident warranted an internal investigation, government inspectors found. Staff had hooded and restrained the teen without first attempting gentler methods, like talking to her.
In an interview with inspectors who eventually investigated, the hospital’s quality improvement director said the facility had no “procedure to contact the (state) for allegations of abuse, neglect or serious misconduct with patients.”
“The tragedy here is that we continue to be scared of people with severe mental illnesses, and so we can keep them on the margins,” Frueh said.
“They’re not a group of people with money or resources. There’s no powerful lobbying groups. There’s no powerful financial incentives for any particular group to take care of them.”
The Seattle Times found that staff at a local mental health facility were using spit hoods to restrain patients. This led to an investigation into how these tools are used inside hospitals, ERs and ambulances across the U.S.
To understand the national picture, The Seattle Times conducted a 50-state survey of state health and social service agencies. This survey was emailed at least three times to administrative agency officials, media relations departments or both. The Seattle Times followed up by calling every state that didn’t respond to initial requests. Twenty-nine states responded, including 15 that said they use spit hoods inside at least one state-run psychiatric facility. Read more about the survey here.
This investigation also relied on federal hospital inspection reports collected and published online by the Association of Health Care Journalists, internal medical facility records, documents retrieved through public records requests, media reports, lawsuits and interviews with more than 30 medical staff, patients, civil rights advocates and legal experts.
Does your department have spit hoods? If so, do you have a use and review policy?
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