Ten months after the new St. Joseph's West 5th campus opened its doors – and more than doubled its forensic capacity – doctors say it is finally "right-sized" and adequately helping the community.

But even as more and more patients are taken in, forensic psychiatry remains shrouded in myth and mystery. There is a perception, St. Joseph's forensic psychiatry head Dr. Gary Chaimowitz admits, that people found not criminally responsible (NCR) for criminal acts are somehow getting a "free pass."

Dakota Hart, the man recently accused of trying to abduct a four-year-old boy from the grounds of Earl Kitchener Public School, is undergoing a 30-day assessment at St. Joe's to determine whether he is criminally responsible for the alleged crime.

If doctors (and the judge, who makes the final call) determine he is NCR, he will go to a hospital instead of a jail. And in the case of St. Joe's, which recently opened its new $581-million facility, a really nice hospital.

But anyone who thinks that would mean he or anyone else is getting off the hook should talk to Warren Skyers, who laughs at the notion that being a forensic patient is somehow "easier" than doing jail time.

"It's not easy at all. I can definitely say that. You mess up and they'll hold you back in for another year," the 29-year-old Milton man said in a recent interview with The Spectator.

In jail, you do your time and you're released — there's an end in sight. Not so, here.

"When you're in the forensic system, you do not know when you're coming out," said Skyers, who spent nine months in the forensic unit last year.

Months. Years. Decades — even forever.

Patients are at the mercy of the Ontario Review Board (ORB), which decides annually whether each person is ready for conditional or absolute discharge; a decision that hinges on the broad definition of whether they are still "a significant threat to society."

The Spectator was recently given a tour of the now fully-functional new forensic unit at St. Joe's, touring the secure facility and meeting patients to give readers a glimpse into the complex world of forensic psychiatry and the intersection of mental health care and the law.

The forensic unit holds people found unfit to stand trial or not criminally responsible for their crimes—what was once called "pleading insanity."

To be found NCR, a forensic psychiatrist needs to determine the accused has a mental illness that was active when the crime occurred, meaning they were not in control or incapable of knowing what they were doing was wrong.

There are 90 forensic beds here for patients, who can come from across the region or province depending on bed availability. Another 20 beds will open over the next few years.

In Ontario, there are 1,800 NCR patients in the system. St. Joseph's forensic psychiatric team (one of eight across the province) assesses roughly 75 people a year for fitness to stand trial—only roughly a quarter of whom are found not fit.

This year, they have done 30 NCR assessments. Of those, 14 people were found NCR and admitted and another five are ongoing.

St. Joe's handles only minimum- and medium-security patients. Penetanguishene is the only site of a maximum-security forensic facility.

Skyers was admitted to St. Joe's after he was declared not criminally responsible for uttering threats against Parliament and Prime Minister Stephen Harper in December 2010.

Skyers, now 29, had been working full time as a travel agent on top of his tourism studies at Sheridan College. He would finish school around 3 p.m., commute to work for 4:30 p.m. and then get home around 1 a.m. only to get back up and start again at 6 a.m.

He was overwhelmed, and found himself "obsessed" with the government and taxation. He remembers making the calls; he remembers being warned not to make them, and he remembers officers showing up at his home.

He went to jail, but knew there was something wrong with his mind. His family and friends, too, were confused — that wasn't like him at all.

"Because the threats were kind of odd… threatening to blow up a building? They're not normal," he says now, in a recent Saturday afternoon interview with The Spectator.

He underwent a mental health assessment and was found NCR; diagnosed with bipolar disorder — something he didn't know he had.

Today he is stable, out on a "conditional discharge" and has been allowed to live at his mother's house in Milton since July. He's now working (though with his criminal record, it's been impossible to get back into the tourism industry) and sees his girlfriend and two kids regularly.

Skyers is a clear success story. He took his meds, took part in programming, sought out services and was discharged into the community within months.

But other patients are here for decades.

NCR is a criminal defence — most often sought by the accused's lawyer, and in some cases sought by the Crown or even the judge. And while it opens the door to a slew of treatment and support services, it is intense. Long. Restrictive.

On one hand, forensic services head Dr. Gary Chaimowitz goes so far as to describe Ontario's forensic system as "magic." But then he also says you would be "foolish" in some cases to plead NCR, even if you are.

But wouldn't that mean there are people in the criminal justice system who very likely committed their crimes because of a mental illness, but who choose jail simply because they know when they will get out?

Likely yes, Chaimowitz says, but St. Joe's is not in the business of recruiting patients.

"People are here under court orders… so you can't just open the door and pull people in," he says.

But he also acknowledges it is unfortunate that it sometimes takes an offence for someone to get the help they need.

"If you are an incipient sex offender, there is nowhere in this country where you can get help until you've offended. Where would you go?" Chaimowitz says.

"It's hard to seek out care before they offend because society views these people with a certain degree of disdain. And then they offend and all of a sudden they're sanctioned and then there is maybe some hope for them."

Substance abuse can also be a barrier to forensic care — drug or alcohol use can make you ineligible for an NCR defence because it is seen as a choice.

Criminal lawyer Beth Bromberg recalls one client she had who had a serious bipolar disorder and was delusional at the time of his offence. But because he was also using cocaine, he was found criminally responsible and went to jail.

"He would have been better off to get the help through the forensic program, and the community would have been better off with him getting help through the forensic program," she said.

However, Bromberg stresses forensic psychiatry is not the only route for treatment for people with mental illnesses who find themselves in the justice system.

Within the court system, for example, there are a number of mental health court staff (at least four or five on site each day) who offer supports and referrals — a resource that was not available when she began practising 27 years ago.

The majority of cases going through the criminal courts have an element of addiction or mental health, she says.

"A very large percentage of accused (people) are committing offences because of addictions and mental health issues."

But even for those who apply, Bromberg says that when it comes to seeking an NCR defence, "you would not make that decision lightly."

In some cases, it's just not worth it, especially if the offence is minor.

Chaimowitz gives the example of someone who might be found NCR for something like breaking a window: "He comes in here and we do our assessment... and find out he's (also) a pedophile who is not responding to treatment. He'll never leave."

Some jurisdictions have full mental health courts that deal specifically with people suffering from mental illness. While the concept is similar to the Drug Treatment Court that was established in Hamilton by Justice Marjoh Agro this year to help offenders suffering from addictions, the city does not yet have a dedicated mental health court.

Skyers said in jail, it seemed three quarters of the guys he met suffered from some kind of a mental illness.

"And it's like, when they're in jail, they don't have the resources to say, 'Hey, I need to go to the hospital. I need to seek treatment.' Because all they think about is lawyers and 'How long am I gonna be in jail for? When am I getting out?'

"But then they get out and nothing is fixed. The problems remain the same and they reoffend and go back in again," Skyers said.

He was determined this wouldn't happen to him, regardless of how long it took.

The new hospital is a far cry from the aged building (now torn down) where he lived. The new one is bright and beautiful — they boast that the entire place has 70 per cent natural light.

On The Spectator's recent tour of the forensic facilities, patient Don Gibson, 32, acts as our guide.

There are five units in total; one assessment, two secure (medium security) and two general (minimum security) units — each one a different pastel colour and a name like Mountain or Harbour or Waterfall.

It's a very "cookie cutter" layout, says clinical director Marilyn Dakers-Hayward — and even the forensic units look identical to the hospital's other wards.

Gibson has lived the last year on Waterfall, a secure unit. Here, in-and-out privileges are controlled by doctors and security personnel, with a series of sally ports separating the unit from the rest of the hospital and the general public.

This separation allows patients to use customizable swipe cards (like the ones staff use) to move around the unit, and to access appointments or the gym — a convenience that was not available at the old hospital.

Their access is limited depending on their assessed risk.

Loading... Loading... Loading... Loading... Loading... Loading...

The first stop after coming through the secure sally port to the robin's egg blue Waterfall unit is a set of lockers where patients can store items like cigarettes, lighters, cellphones or laptop computers.

These things can be used — if privileges, earned over time, allow it — but not on the unit.

Each patient gets their own bedroom with their own bathroom and closet. Each one has a large picture window. For privacy, patients can lock their bedrooms using their swipe cards — other patients can't get in, but doctors can.

Each bedroom door has an anti-barricade panel that allows staff to pull open the door in an emergency.

It seems they've thought of everything.

"I wish we had," Dakers-Hayward laughs.

Around the unit, there are fresh flowers in common rooms and inspirational quotes taped on the walls. One of the TV rooms is still decorated with tiny paper flags, left over from the World Cup.

There is a piano, TVs, a computer equipped with basic non-Internet programming — though Gibson is part of a team working on opening a computer lab with Wi-Fi for the patients. In the kitchen, there is a small fridge where patients can store their own snacks for when the cafeteria is closed.

It looks nice, like a typical modern hospital. But security is on high alert. It is a reality that some of the patients here are violent.

Forensic patient Tyler Michael Valcheff, 33, pleaded guilty to manslaughter for punching Michael Brewer (another forensic patient) to the ground and stomping his head and neck when a seemingly innocuous smoke break turned violent on May 23, 2012.

Once NCR does not mean always NCR.

"We're not going to stop violence... what we do is we change the odds. We need to be held accountable if we fail, that's for sure. But the question is, was that a predictable thing? If we could stop violence, they would be parachuting us into Iraq and Syria... but we can't," Chaimowitz says. "Our task is to change the odds."

That being said, it is difficult to quantify the successes of forensic psychiatry, he says.

"It's always easy to count victims… but what you can't count are the people who could've been victims (of our patients) but who are not, because people have been treated," he says.

"Many of our patients who might be assaultive… if we can reduce their assaults from 10 a year to one a year, there are nine people who (are protected)."

From the nursing station, staff has a clear view down the two hallways of bedrooms and common rooms where patients mull about. And a modern GUI (graphic user interface) keeps track of every move on the ward.

If any staff member has a problem, they press a button on the alarm that hangs on their lanyards along with their swipe cards. The second the alarm is sounded, their photo and location pops up on the GUI so that staff can act immediately.

There are only 12 people on the unit during The Spectator's visit. The opening of a second secure unit in the hospital just a week earlier left 10 rooms free.

"We told everybody not to get used to it," Dakers-Hayward smiles.

Being a new hospital, there are facilities they haven't even used yet — like a negative pressure room that they could use in case of contagious disease, which would allow a sick patient to remain on the unit.

And a pair of transitional apartments will allow patients who are getting ready to be discharged to take a practice run at living alone before leaving the hospital. After all, many spend years here.

At first, Gibson seems nervous. He knows the stigma around mental health.

"People have this set notion of what (NCR) is… people don't quite get that when someone is NCR, they really don't know what they're doing," he says.

NCR is not an alternative to jail, he stresses. Nobody is getting a free pass.

"It's not anybody's 'fault.' They are schizophrenic, bipolar… How do you hold someone accountable when they don't know what they're doing?" Gibson says.

Chaimowitz agrees — there is a very specific legal test that declares these people NCR.

"Our purpose is to provide resources and services for people with mental illness who, through no fault of their own, have run into the criminal justice system… If it was their own fault, we're not seeing them. They're in detention centres and like any of us they pay the price," he says.

"One in five Canadians has some sort of a mental illness, and it doesn't give you a free pass."

In his time here, Gibson (who was declared NCR for an aggravated assault) says he's taken full advantage of the programs and services.

"It's surprised even me," he says of the program.

Things like weekly cooking nights, expert talks in the auditorium. He works out in the gym. Plays basketball and volleyball. He has also taken part in collaborative programming that's allowed patients to be involved in decision-making processes, like a recent hand-washing initiative that recruits patients themselves to audit staff. And a panel he took part in, during the hospital's hiring of a lawyer.

"I thought it was great to be part of that… it's a good experience to work with the team and it's kind of a collaborative project," he says.

Gibson has no idea when he will get out, but his focus is on rehabilitation.

One thing at a time. For him, the forensic system has been life-changing. Literally.

But as part of the larger system, Chaimowitz acknowledges that people with mental illness are "overrepresented in the criminal justice system."

That is something that needs to change. It is unfortunate that it should ever take committing a crime to get help.

"In an ideal world, the whole mental health system functioned as it should; people got services on time, all the time when they needed it; hopefully, nobody would commit offences based on their mental illness. If we had housing, enough supports, reduced the amount of addictions in society... our numbers would be lower," he says.