1. Background

Parental mental ill-health is a major public health concern with an extensive body of international research demonstrating the significant challenges faced by parents, children and the family [1, 2]. These families may experience multiple, interrelated and compounding challenges, both within individual members and across the family system, which can fluctuate over time. The causation and consequence of individuals’ needs are bidirectional, with the parents’ needs impacting children and the challenges of looking after children impacting the parent [3, 4].

These families have complex needs caused by both individual factors (e.g., physical and mental illness, substance misuse, disability or developmental disorders), socioeconomic factors often associated with mental ill-health (e.g., poverty, insecure housing, exposure to family violence or criminal justice) and societal factors (e.g., discrimination, stigma, austerity and a neoliberal political approach to welfare) [5–7]. These compounding difficulties compromise the quality of life and opportunities for all family members [8] and necessitate the need to engage with multiple services. These include, but are not limited to, services related to mental health, child and family support, drug and alcohol use, welfare, housing, child development, physical health and education.

To effectively respond to these complex needs, professionals signpost and refer families to multiple sources of support. While driven by the intention to connect families with specialised services, this can inadvertently add to the complexity of navigating support systems, overwhelming families and increasing the risk of service disengagement [9]. Within a complex system, “families not only need to navigate the labyrinth of the healthcare and social care systems but also be adept at distinguishing the responsibilities and expertise held by practitioners of different professions” ([10], p. 60).

Professionals may also feel overwhelmed by the complexity of family needs due to limited knowledge, inadequate support, or the constraints of a fragmented system, where rigid bureaucratic processes and inflexible service boundaries can hinder direct intervention [11]. In the UK and many western countries, statutory services are positioned in distinct quadrants of health, social care, child and adult [12] which has led to the erosion of professional discretion and the capacity for holistic or integrated practice [7]. Many services are designed around specialisms which means that families with multifarious needs typically receive numerous services both horizontally, across service domains, and vertically, across generations [13]. In some cases, the complexity of navigating these services may become a barrier to accessing support [6].

Multidisciplinary collaboration is widely accepted as an efficient use of services, skills and expertise [14]. Likewise, effective collaboration between agencies enables a comprehensive response to complex needs, reducing service gaps and improving accessibility [11]. However, despite numerous policy directives and implementation strategies, practitioners in adult- and child-focused agencies continue to cite significant professional and organisational barriers to collaboration [15].

The rationale for this systematic literature review is grounded in the growing complexity of service provision. To illustrate, a case file audit of families in Northern Ireland highlighted the intricate network of services families navigate, involving an average of 12 different health or social care services [16]. Notably, the audit was based on social services files and so may not have included records of all relevant education, welfare, housing or third sector organisations, suggesting that the actual scope of support systems is likely broader. Similarly, other studies from Norway and Australia have shown that families where a parent has mental ill-health receive multiple services for health, mental health, criminal justice and child welfare [15, 17], underscoring the need to provide these families with support to navigate complex systems. Attempts have been made to redress this, from policy directives [14] to service initiatives and professional champions [15, 18] and interventions to educate and advocate for families [9, 19]. However, the implementation and sustainability of these approaches are as varied and fragmented as the issue they are seeking to address [20].

Given the complexity of both the challenges faced by families and the service provision landscape, several members of this paper’s team conducted an innovative review of the literature to explore system navigation and management [9]. Evidence spanning from eight academic disciplines, each focused on managing complex systems, was examined to identify insights that could be applied to support service users in navigating health and social care services. The review provided evidence that for services and navigation tools to be accessible and effective, service users must be central to their design and iterative evaluation [9]. Others have also argued that meaningful and central involvement of service users in the design, delivery and evaluation of services promotes the values of epistemic justice, control and choice; this has historically been lacking for adults and children living with mental ill-health and navigating and/or being subject to health and social care services [5, 21]. Thus, collaborating with families is essential when designing navigational tools or other forms of interagency or sectoral approaches [22].

It is important to ensure that further development in the field is grounded in existing evidence and that the perspectives of service users are central. Hence, a literature review centralising the voices of people navigating multiple services is imperative.

2. Methods

2.1. The Current Review

The focus of this qualitative evidence synthesis was to understand the lived experiences of parents and other immediate family members (partners, co-parents and children) where a family receives services from multiple provisions including but not limited to adult mental health care, social care (child and adult), physical health (child and adult), education, housing and welfare.

2.2. Definitions

The review used but was not limited to the term “navigation” and instead employed an expansive stance, which encompassed, awareness of available resources, accessing services, understanding the links between different services, communicating with services and feeling able to have the needs of you and your family understood and met. Our working concept of ‘navigation’ has been the focus of ongoing collaboration by the author team as part of the International Research Collaborative for Change in Parent and Child Mental Health. Emerging from the original study [16] that examined the number and complexity of services that families were expected to ‘navigate’, the team has conceptualised the term ‘navigation’ to help understand how families are supported to manage complex services, their lived experiences and how coproduction might help improve interfaces. Likewise, a broad definition to parenting and family was used, with both parenthood and family not being restricted to biological relationships or living arrangements. Mental ill-health was not restricted to diagnosis but defined as any condition which requires support from services, such as medication, care coordination, community services and inpatient care. It was recognised that the concepts of family and mental ill-health may vary across cultures, circumstances and time, and this was considered in the inclusion, screening and analytic process.

2.3. Review Team

Adopting a team approach ensures a review incorporates rigorous content expertise and insights from different perspectives [23, 24]. Daubt et al. [25] illustrated the importance of incorporating research and clinical perspectives. Aligned to the team’s commitment to academic rigour and epistemic justice and following the findings of the interdisciplinary review, which evidences the need for ‘service users’ to be central to any design or review [9], three people with lived experience were invited to be part of this review. An international team of nine academics and clinicians with a range of professional backgrounds was also included. The inclusivity of this team approach and the incorporation of both lived and learnt experience add an original facet to the review methodology and significantly increase the rigour of the analysis and findings. The research team represents a range of different professional disciplines, from mental health social work, mental health nursing, psychology and counselling, political science and occupational therapy. Lived experience of service use was also represented. Regular meetings with the research team were used to discuss coding decisions, theme development and interim findings. The primary researcher facilitated the engagement with the lived experience co-authors.

2.4. Inclusion of People With Lived Experience

The contribution of the lived experience researchers was based on the principles of research co-production [26] to complete the evidence synthesis with an approach based upon the ACTIVE framework being used [27]. The lived experience researchers were recruited via previous collaboration with the primary researcher. The lived experience research group comprised three members: one mother and one father, both with lived experience of mental ill health and long-term involvement with secondary mental health services, and one young adult who grew up with a parent with mental ill health and chronic physical health needs. Two members of the group identified as White and one as Black. While the lived experience research group was small, it brought together diverse familial roles and experiential perspectives. Their different standpoints informed the design of the review, the interpretative analysis and added supporting reflection on how parental role, caring position and service histories shaped the meaning and relevance of the findings. The team contributed to critical discussion of interpretations and helped identify areas where assumptions or dominant service narratives required further scrutiny. Key insights that rose from reflections on their own experiences related to (but not drawn from) the papers reviewed were reported at the end of the discussion as additional insights.

2.4.1. Mode of Involvement

The lived experience researchers were involved with three ‘one-time activities’ at key points of the review (Table 1), and ‘continuous involvement’ with the primary researcher, maintaining regular contact and providing oversight of the project process. Due to the lack of available remuneration, they were not asked to engage in the screening tasks for the review; however, the primary researcher kept them informed of progress throughout. Equally, in response to the technical and temporal challenges of international meetings, they chose to meet with the primary researcher in person, where they could articulate their input in a manner which did not feel overwhelming or pressured. Using the ACTIVE continuum of involvement [27], the researchers with lived experience involvement were considered influential, in that they provided data and feedback that directly influenced the review but without direct control over the review process.

2.5. Supporting Involvement and Well-Being Considerations for Lived Experience Contributors

This review was conducted as an unfunded project which limited the level of involvement that could reasonably be requested from lived experience researchers, as no financial compensation could be offered. In response, involvement was designed to be proportionate and flexible with demands kept manageable with regular check-ins by the primary author to ensure contributors were comfortable with their role and level of engagement. Meetings were held at locations convenient to contributors, and refreshments were provided. Given the size and international composition of the academic research team, involvement was structured through smaller supportive discussions rather than full team meetings to reduce potential barriers related to confidence and logistics. For future reviews or larger projects funding would be key to ensuring that appropriate financial compensation and enhanced support could be provided to strengthen inclusion of lived experience researchers across all stages of the research process.

2.6. Research Questions

1. What is the nature and scope of existing qualitative literature exploring the experiences of parents who have mental health challenges receiving multiple services to meet their needs and that of their families?
2. What does the research tell us about these experiences? Specifically, what challenges and/or facilitators to navigating and engaging with these complex systems of care do parents and their families identify?

2.7. Search Strategy

Preliminary searches were conducted in collaboration with a university librarian (Table 2). A search strategy was developed to optimise the retrieval of relevant articles (see Appendix A). Search terms were developed with the incorporation of Boolean operators and truncation. Filters were applied including peer-reviewed, written in English, to ensure recency; articles published post-2014 were included.

2.8. Selection Criteria

The purpose of the search was to identify qualitative primary research that focused explicitly on the experiences of parents with mental ill-health engaging with, accessing, and receiving multiple services for themselves and their families. Accounts reported by parents, partners and children would be included.

2.9. Study Selection

Searches were conducted across seven databases (APA PsycINFO, Academic Search Ultimate, Complimentary Index, Medline Ultimate, CINAHL Ultimate, ERIC and Scopus) yielding 10,460. Duplicates were removed, leaving 7,232 (Figure 1, PRISMA flowchart). An initial search was conducted in January 2024 and repeated in February 2025 prior to publication.

Due to the potentially ambiguous nature of the subject and the wide range of terminology it was necessary to screen by title and abstract in the first instance. This task was shared by the research team with each paper screened by two people. Many of these initial papers did not focus on parental mental ill-health but rather parents’ experiences of accessing services for a child with mental ill-health or the mental well-being of parents caring for a child with physical health conditions. Many studies were also removed as they exclusively investigated the experiences of professionals providing services to families where a parent has mental ill-health. The title and abstract screening resulted in 64 remaining entries. Full text screening was conducted on the 64 articles, again independently by two members of the team, and reasons for exclusion were recorded.

Articles were screened in accordance with the following inclusion/exclusion criteria.

2.9.1. Inclusion Criteria

• Adults with mental ill-health who are parents of children under 18 and are currently receiving or have received multiple services for their mental health and the needs of their family.
• Family members of the above adults
• Peer reviewed, qualitative studies reporting empirical evidence.

Additionally, we included studies that:

• Reported participants’ experiences of receiving multiple services, even if the study focused on a specific intervention, program or service, if the findings referred to other services provided.
• Highlighted experiences of engaging with multiple professions from different services or disciplines.

2.9.2. Exclusion Criteria

2.9.2.1. Studies Were Excluded That

• Focused solely on professionals’ experiences of providing services. If a study included both professionals and service users, findings, data pertaining to professionals’ views were excluded
• Focused on adult children who were caring for a parent with mental ill-health later in life.
• Focused on a single intervention, program, or service with no reference to other services.
• Did not present primary qualitative data.

Sixteen articles fulfilled the inclusion criteria and were quality assessed before being included in data synthesis (see Table 3 for study characteristics).

2.10. Quality Assessment

The Critical Appraisal Skills Checklist (CASP) was employed to determine the methodological quality of the papers as optimised by Long et al. [28] for qualitative evidence synthesis. The sixteen included papers were independently quality assessed by the primary (KB-H) and a secondary reviewer (CMcC). Due to the limited research available in this area, papers of a lower quality were not excluded. Sensitivity analysis was not conducted. As people’s experiences were the focus of the review, study quality was considered to be less of a concern as long as the themes emerged consistently across the data. Although CASP has not been designed with a scoring system in mind, guidance sets out that if the first three questions are answered ‘No’ it is considered likely that the quality is low. All of our included studies met the checklist criteria for questions 1–5, 8-9 and mostly for item 7. Criteria were not met for consideration of researcher/participant relationship (question 6) or a clear description of the theoretical underpinnings of the study (question 10) which we considered unlikely to influence the research findings and indicate the quality of the evidence was high [29]. An indicative summary total has been included and scored (1 for ‘yes’, 0.5 for ‘unclear’, and 0 for ‘no’) as described in Smith et al. [29]. The quality of assessment ratings for the included studies is illustrated in full in Table 4.

2.11. A Reflexive Thematic Analytical Approach to Thematic Synthesis

The theoretically flexible interpretive approach of reflexive thematic analysis (RTA) facilitated the identification and scrutiny of patterns and themes within a dataset [30]. The reflective approach to thematic analysis in the model highlights the researcher’s active role in the knowledge production, with the interpretive analysis of the codes being situated at the intersection of the researchers’ own analytical skills, knowledge and theoretical assumptions [31]. This approach utilises the unique skills and experiential resources of the research team. However, it is acknowledged that the interpretations and analysis of the data are subjective to each individual researcher. To facilitate sense-checking, the exploration of multiple assumptions and interpretation of the data, coding and analysis were conducted by multiple members of the team. It is key at this point to remain cognisant that RTA is not intended to provide a single, correct, accurate answer but rather to celebrate the richness of qualitative data by striving to achieve deep interpretations of meaning through collaboration and reflection [32].

Following Braun and Clarke’s six phases of RTA, two academic members of the research team (KB-H, CMcC) completed the initial three phases of the analysis process with the whole research team collaborating to complete the final three (see Table 5). Here, the strength and diversity of the reviewing team were key, particularly the inclusion of people with lived experience. Two authors (KB-H, CMcC) coded the primary data, entering the first-level codes and outline themes with supporting quotes in a shared Google Drive MS Word document in table form. Conflicts were discussed and resolved with a third author (GD). Regular meetings were held with the research team to give feedback on the theme development, and these were further refined as a result of discussions (as detailed in steps 4-6 in Table 5).

3. Results

No studies were found that explicitly explored the experiences of navigation of complex networks of services across multiple agencies and disciplines. In response to the first research question, which sought to identify the scope of research in this area, a significant gap in the literature has been identified. However, in response to the second research question, exploring the experiences of engaging with and navigating complex systems of support, data extraction focused on the experiences of engaging with multiple services and/or professionals.

3.1. Study Characteristics

Of the 16 studies there were six papers from the USA, four from the UK, two from Canada and one that was conducted across Finland and Scotland. The other three were from Australia, Sweden and China. Eleven of the studies spoke exclusively to mothers, four included fathers and one focused on fathers as caregivers for a mother with mental ill-health (N = 417 (mothers, n = 387; fathers, n = 26; grandmothers, n = 4). Of the six studies which explored the experiences of engaging with outpatient and community services, five focused on mothers (1, 6, 15, 3, 16) and one included father (7). One study focused specifically on young mothers (6), another on parents with anorexia nervosa (3) and one on mothers diagnosed with a borderline personality disorder (16). Four studies presented the recollections of parents accessing services related to mental ill-health and substance (mis)use; two focused on mothers (4, 8) and two included fathers (2, 9). Three studies attended to the peri- and postnatal period, two involving mothers (5, 14) with one focusing exclusively on immigrant mothers (5) and one reporting the experiences of fathers who were partners of mothers admitted to a mother and baby unit (12). One paper included mothers who were admitted to a psychiatric inpatient ward (11). Finally, two studies presented the experiences of parents with mental ill-health who were also engaged with legal child protection/custody processes; one included parent of either gender (10), while the other focused solely on mothers, including four grandmothers (13).

3.2. Thematic Synthesis

Within the predetermined themes of inhibitors and enablers, several subthemes were identified that related to individual, profession and service factors as per Figure 2.

3.3. Inhibitors

3.3.1. Individual

3.3.1.1. Histories of Multiple Services

Many parents across the identified studies described multiple and intersecting psychological barriers which inhibited help-seeking and service engagement. With long histories of mental distress, trauma and adversity, their expectations of services and their ability to navigate them were poor [33–35]. Previous interactions with both child welfare and mental health services were described as traumatic [36–38], as were some interactions with services for physical health or when pregnant [39]. It was clear across the studies that experiences where an individual felt dis-respected, misunderstood and mistreated by a professional or a service not only damaged the individual’s relationship with that particular service but also impacted their expectation and experiences of other services both immediately and in the future. At times this was exacerbated further by participants’ childhood histories and current family networks which Jack et al. [34] described as a continuation of stressful relationships characterised by abuse, exploitation and unavailability. These relationships had the potential to not only exacerbate mental distress but also carry intergenerational narratives and current fear or threat of engaging with services which would prevent navigation. For some this was also an illustration of a lack of understanding from professionals (both child and mental health) as they encouraged the involvement of family members without understanding the history or potential harm.

3.3.1.2. Symptoms and Schemas of Mental Ill-Health

Regardless of the service discipline or focus, the symptoms of mental illness could prevent parents from expressing their needs or accessing support [36, 38]. In Fitzpatrick et al.’s [40] study, participants linked Anorexia Nervosa and motherhood as “conspiring together to prevent them accessing treatment” (p. 1147) in which the mental health challenges they faced were unwittingly compounded by maternity services who were focused on feeding and weight. This description of shame and the belief that they were not ‘deserving’ of support, mirrored the social narrative of the ‘selfless mother’ who should be able to cope [33, 34]. Both fear of stigma and internalised stigma led parents to feeling that they needed to disengage from mental health services to distance themselves from the negative connotations of mental illness and be seen as a good parent [36]. Their fear of being judged extended beyond themselves as an ‘unfit mother’ [33, 35, 41] to their children and the fear they would be treated differently at school [36]. This interpretation of the need through the lens of their mental ill-health could lead a parent to actively avoid or assume other (nonmental health) services were unavailable to them. This meant that they were unable to access universal services such as parent and child groups.

3.3.1.3. Perceived Correlation Between Mental Ill-Health and Child Abuse or Neglect

The experiences of stigma and preconceived judgement from professionals were felt keenly by parents with mental ill-health, especially with a diagnosis of Borderline Personality Disorder [35] or substance mis(use) [37, 41–43]. In Kim et al.’s [37] study, this extended to mothers being reluctant and guarded about seeking healthcare for their child, as they believed “there was no room for parental mistakes” (p. 103), meaning they would be judged more harshly than another parent for minor errors such as missing a doctor’s appointment. Thus, they were less likely to make a doctor’s appointment or discuss concerns about their child with a teacher.

Fear of child protection and loss of custody was explicitly discussed by parents in six studies. This was not exclusively parents who had had previous experiences of child protection (as a parent or a child) [37], suggesting the fear was rooted in the negative stereotype of social workers and child protective services [36] and the stigmatised stereotype that mental ill-health would be automatically correlated with unsafe parenting. In terms of engaging with and navigating multiple services, health services were seen as more acceptable to parents than social services or child services [36]. However, for some the fear of a correlation being made between mental ill-health and child abuse or neglect resulted in a complete avoidance of services or a minimisation of needs regardless of professional or service background, as they feared that if they spoke openly about challenges, it would be used against them as a child protection referral or evidence in court [33–35, 38].

3.3.1.4. Competing Needs of Parent and Child Across Services

When considering their mental health needs, parents described having to put the needs of their children above their own and no longer having time to engage with services for their mental health [33]. Parents who tried to balance meeting their child’s needs with managing their own mental health, spoke about avoiding disruptions to their child’s routines in order to attend multiple appointments [34] or refraining from involving them in meetings they felt could be distressing [41]. There was also a sense of guilt about the impact their ill-health and accessing services had upon their partners [41, 44]. Parents highlighted the perceived impossibility in accessing acute inpatient care, as the emotional impact of their separation from their child was inconceivable [38, 40]. In trying to balance these competing needs, parents noted that “a lot of places focus on the parent or the kid, but not really focus on both” ([43], p. 2126) and that mental health services in particular were dismissive, with staff seen as having “no interest in my baby” ([38], p. 160).

3.3.1.5. Practical Barriers to Multiple Services

Parents spoke at length about the practical and logistical barriers to accessing multiple services for their mental health and their family’s needs. These were often grounded in socio-economic hardship arising from being homelessness [45], a lack of transport [34, 37, 46] and a lack of childcare, especially with infants or appointments outside of school hours [34, 46]. This is made worse by multiple appointments with different services “You have to go to A, B, C, D. Then you have to do all the travelling… and you have these kids and not so much money” [33] coupled also with a fear of travelling and attending appointments alone [37, 46].

The process of accessing services such as a telephone screening process was difficult, particularly within the context of their mental illness symptoms and for those whose first language was not English [47]. Access to many services was further complicated by complex eligibility criteria and restrictions which could be based on primary diagnosis, finances, insurance, geography or immigration status [39, 47]. Once accepted to any given service, many parents were faced with long waiting lists along with uncertainty of when they would be seen, what this would entail and how it would fit with the service(s) they were currently engaged with [37, 46, 47]. Participants in DeCou and Vidar’s [33] study described disliking the frequent change of professionals and so actively avoided a new service as they feared it would mean losing the therapist they currently had.

3.3.2. Professional

3.3.2.1. Ill-Equipped to Navigate Services

Parents felt that professionals were not able to provide adequate care and appeared to be overwhelmed by their various issues. In Powell et al.’s [45] study, a parent with mental ill-health, substance (mis)use and an active child custody dispute described how each issue impacted the others “my therapist; she just gave up… she just ignores my calls” ([45], p. 5). According to parents, the complexity of their needs left professionals feeling ill-equipped to assess need and make appropriate referrals [37–39, 45]. Participants in Jones et al. [36] identified a lack of collaboration and interaction between services, which they felt led to professionals sometimes being unaware of the support available.

3.3.2.2. Professional Harm

For some parents this could lead to what they perceived as judgemental comments and a punitive approach from professionals “feeling judged, neglected, dehumanised and constantly monitored” ([37], p. 102). Such a rupture in the therapeutic relationship not only prevented support and benefit of a service but also damaged future relationships across a wide range of services for that parent [35, 38, 40, 43, 45, 46]. Worse still, it can cause harm to parents’ confidence [37, 38]. This erosion of connectedness and parents’ confidence carried a significant risk of increasing future needs, potentially requiring engagement with multiple support services. At the same time, increasing potential to create fear and mistrust in those services, which may hinder future engagement and navigation. One participant in Fowler et al. [42] described her relationship with her midwife, “Took away the joy that I should experience as a mum and not those emotionally loaded terms such as “methadone baby”. You know, I just felt, I felt like I wasn’t worthy, that I was a second-rate mum and that I didn’t deserve the support that the other mums got.” (p. 2839).

3.3.2.3. Professional Dominance and Contradictory Recommendations Between Services

Parents’ concerns and preferences were at times at odds with professional recommendations, leaving them feeling dismissed [35, 46] or in extreme circumstances coerced [38]. The perceived power imbalance and lack of alliance can mean that an intervention became a “vehicle for opposition and resistance” ([40], p. 1147), a position that would be taken forward into other (and future) services, “I almost dreaded going, because it was just like, you know, every time I went, I knew that she would badger me about going to the eating disorder unit” (p. 1147). For example, in mental health services, the primary professional focus was seen by parents to be medication [39]. This could be particularly problematic for mothers who viewed psychotropic medication as conflicting with their identity and role as a mother, especially due to concerns about breast milk contamination and sedation interfering with the parenting standards required by children’s services [48]. This created a significant challenge for parents engaged with multiple services, each giving contradictory information and recommendations. “So, here you are being ping-ponged back and forth, what do I do?” ([37], p. 103). Many parents attributed this confusion to the prioritisation of service needs over the family and a lack of family focus understanding [46].

3.3.3. Services

3.3.3.1. Lack of Inpatient Family-Focused Provision

There was little evidence that family-focused practice extended beyond a small number of specialist interventions. Indeed, even in a specialist service for families affected by substance (mis)use which identifies the “family unit as the client”, parents and staff perceived that services in general were focused either on the child or the caregiver and seldom both [43].

To illustrate, set within an in-patient service Powell et al. [38] reported a lack of family rooms, the ward not feeling like a safe place for family members and children to visit and inflexible visiting hours which prevented contact. Mothers did not feel their identity as a mother was considered, with a dissonance between the staff’s focus on the ‘patients’ mental health, while the parents’ primary concern was the wellbeing of their child, “I don’t really have time to fix myself my only focus is giving the kids the best possible life.” ([33], p. 2258). Likewise, several mothers reported that staff discouraged them from talking about their children or to other parents on the ward about their children. This resonates with Zacharia et al. [35] study which suggests that unless the parent was admitted to a specialist mother and baby unit, the need for parent/child contact was not always acknowledged (2021).

3.3.3.2. Fragmented Provision and Inconsistent Thresholds Between Services

Lack of collaboration and interaction between agencies and services meant there was a lack of awareness of available resources and support [36], resulting in unsuitable or missed opportunities for referrals. When multiple referrals were made, parents were subjected to numerous screening and initial assessments, which some perceived as a threat to their privacy and “emotional safety through multiple requests to repeat their medical histories” ([34], p. 7). The inclusion of new services could also mean losing another and a potential loss of a trusted professional relationship [33].

The fragmentation of service provision and the restrictive eligibility criteria meant that many interventions were time-limited and/or issue-specific. Some parents expressed frustration that they are caught in a “catch 22” in which they are not able to access services until they are in a crisis but then are reprimanded for not working with professionals to prevent such a crisis ([35], p. 597). This could become extremely serious when the thresholds of risk and response differ across mental health and child protection services.

3.4. Enablers

3.4.1. Individual

3.4.1.1. Being a Parent

For many parents, becoming a parent was a transformative event which motivated them to overcome difficulties and gave them the strength to seek help [34–36]. For some the identity of ‘mother’ subsumed the factors which had previously prevented them from accessing support “it’s not just me anymore. It (seeking mental health care) was for the baby. I didn’t care what everybody else thought” ([34], p. 6), giving them additional motivation and confidence to navigate multiple services. In contrast, Fowler et al. [42] found that some mothers’ mental ill-health meant that they imposed a “form of self-disciplining and self-imposed isolation from other women with young children” which made accessing any services outside of mental health extremely difficult. This avoidance included universal services such as mother and baby groups and advice from professionals such as Health Visitors and Early Years workers.

3.4.1.2. Informal Support to Navigate Services

Across several studies there was a clear indication of the value parents attributed to the practical and emotional support family members gave them to navigate services. “Family members, including spouses and the participants’’ children, were important for many participants. For example, one participant explained, “I have my family, who are the support people, really.” Likewise, one participant stated, “The support people in my life are basically my fiancé, my brother and my family.” ([45]. P 112). Family support included supporting self-referral processes, keeping track of different services and professionals, attending multiple appointments, sharing information across services and agencies as appropriate and advocating for their loved one when they were too unwell to do so for themselves [39, 44, 45]. However, for many parents, often with the most complex needs, such as those with no extended family or those with additional challenges such as substance (mis)use, domestic violence or having a child with additional needs, access to peer support was particularly important [33, 38, 43]. Having an opportunity to meet other parents who had similar experiences and could understand the challenges faced offered opportunities for nonjudgmental support and advice while also improving engagement and navigation across services. Fitzpatrick et al. [40] and Jones et al. [36] illustrated how this could also provide a sense of belonging, build confidence and give the opportunity (for some) to adopt an ‘expert’ identity, becoming the “spokesperson for their tribe” ([40], p. 1150), advocating for new parents and training professionals.

3.4.2. Professional

3.4.2.1. Professional Expertise and Flexibility

Having a professional who was knowledgeable and had insight into the parents’ needs was important [33]. A desire for family-focused practice was also explicitly discussed, with professionals who can facilitate family interactions, support the best interest of the child and ensure the safety of the mother in recovery [43]. This entailed professionals having knowledge of other services and an ability to engage with multiple services to put a team around the family beyond signposting [33, 44, 46].

However, a positive response to the complex needs experienced by families was not always the expansion of an equally complex support system of multiple services, but rather the ability to step outside of traditional professional roles to attend to concrete immediate needs. For example, a therapist who would suspend the agenda of her session to offer immediate and practical assistance when required: “When the lights got cut off, she made phone calls while we were in the session trying to find somebody to help get them back on” ([46], p. 343). Young et al. [48] reported a participant’s appreciation for a psychiatrist who taught “concrete skills to manage the emotional challenges of being a parent and normalising the experience of parenting” (p. 939). This role flexibility went further, and a mother involved with family law proceedings praised her attorney for her willingness and ability to discuss her mental ill-health despite it not being her area of expertise. “She wanted to know exactly about my mental health, bluntly, no hiding things so she can help me.” ([45], p. 5). This flexibility of role not only increased trust and promoted collaboration with a parent but also reduced the potentially harmful experience of trying to navigate multiple services at a point of heightened need or crisis.

3.4.2.2. Therapeutic Relationship Mitigates Barriers to Navigation Across Services

When considering the ways that practitioners and/or professionals could enable parents to engage with and navigate professional support, key professional attributes were knowledge, skills, resources and empathy [34]. While these were all desirable, it was clear they were not necessarily inextricably linked to a particular professional discipline or service.

The willingness to build an honest open dialogue reflected a focus on relationships rather than expertise and demonstrated a desire to understand the client as an individual [38]. Believing the professional had a genuine motivation to help was considered by parents to be the cornerstone of a positive therapeutic relationship, one that feels mutual [33], trustworthy and nonjudgemental [35], consistent [34] and supportive [45]. This was demonstrated through personal qualities perceived by parents as approachable, kind and honest [46]. The relationship between parent and practitioner could either facilitate or hinder engagement with services, as well as influence future interactions with services and professionals [34].

3.4.3. Service

3.4.3.1. Navigating Across and Between Services

For parents to be able to build positive relationships with professionals and benefit from their expertise and training, the provision of services needed to be accessible and appropriate. To effectively navigate a system of support which involved multiple services, a parent (or family) had to know which services were available to them, what they did and how they could communicate with them. These findings are drawn from a small number of participants spanning the review who reflected on obtaining the right support when they needed it and who identified the factors required to engage with and navigate across and between services.

3.4.3.2. Whole Family Provision

Wrap-around services, which included clinicians, peer mentors and parenting support to assist parents and their children together, were highly valued [45]. Young et al. [48] described the benefit of an embedded model where “having their psychiatrist present at the same location where their children receive care so they could meet their own needs and their child’s needs simultaneously” (p. 937). By acknowledging and providing for the child’s needs, parents’ trust in the mental health clinic was fostered “because their children had received good care there [and] this had facilitated their acceptance of the offered services” ([48], p. 937). As a result, services could be offered proactively rather than being initiated by crisis or reliant on parents or family members seeking them out.

3.4.3.3. Accessible

Several studies suggested that services should be based in accessible community settings, such as primary care buildings, schools or libraries [33] and/or be co-located with other services such as housing and financial assistance. This holistic approach to service delivery could enable awareness, access, communication and collaboration [47].

3.4.3.4. Flexible and Responsive

The dynamic and unpredictable nature of both parenting and mental ill-health was a recurring theme. For many parents this underscored the need for services that offered flexibility. Flexibility encompassed offering appointments during evenings and weekends and understanding when parents might need to cancel and/or reschedule at short notice. Likewise, the ability to contact service providers and practitioners by text message was requested [34, 47, 48]. Parents also wanted services that were responsive to their personal and cultural needs [36, 39, 47] and their specific needs as a parent as described by Young [48]: “participants expressed concerns about using psychotropic medication specifically because of their roles as mothers (e.g., contamination of breast milk and sedation interfering with parental duties)” (p 937). They called for a range of services that offered a different range of types and levels of intervention which included; short-term solution-focused interventions that could “help them get back on track” ([33], p. 2259), consistent long-term support with an individual practitioner with whom they could build a relationship [35, 48], practical support with basic resources such as housing, food and emergency finances [46], and the availability of emergency/crisis appointments [46]. Quick access to flexible services as a matter of urgency has the potential to prevent long-term deterioration, as expressed by several mothers in Zacharia’s [35] study who “described not feeling heard or understood by professionals. They felt that they should have been able to access mental health support before reaching crisis point, and they described frustration around this” (p596).

4. Discussion

This review aimed to identify and synthesise the experiences of parents with mental ill-health as they navigated multiple services for themselves and their families. It was evident that significant gaps exist. Firstly, there is no dedicated research that specifically explores the complexities of navigating services across various sectors. Secondly, there is a notable lack of research that prioritises service recipients’ voices in the evaluation of services in this field. However, studies were included where participants discussed multiple services, despite no specific reference being made to the navigating of services. It is in this manner that the research team focused on the intersections between services, drawing key inferences and examining them through the lens of navigation. Although these studies were dealing with largely comparable (Western) health and social care systems, parent and child experiences are likely to be similar across different settings. Poor mental health impacts everyone in the family, and while support and help may be available, it can be overwhelming for parents to navigate complex care. Additionally, the associated stigma and shame often experienced by parents and the power imbalance described between professionals and family members create barriers to accessing support.

4.1. Inhibitors

Psychological barriers emerged as a prominent challenge for parents, often rooted in stigma, past trauma and isolation. Perceptions of risk and benefit associated with different agencies resulted in a lack of trust in the entire support system as parents feared that information would be shared between agencies and had the potential to be weaponised. Practical barriers, such as the time and financial strain of attending multiple appointments, were also key, alongside the logistical requirements of understanding roles and thresholds and communicating across different services.

Parents also described individual professionals who were ill-equipped to address their complex needs, giving contradictory advice and failing to understand other available services. The fragmented nature of service provision caused inadequate communication and collaboration across agencies, leading to missed opportunities and repeated assessments, further complicating the process of accessing the right care. Moreover, parents found that many services lacked the flexibility needed to accommodate the unpredictable nature of parenting and mental health challenges, causing parents to feel that they either adhered to rigid schedules or forego care entirely.

4.2. Enablers

Despite these barriers, several enablers were identified, albeit at the individual level. For many, becoming a parent acted as a powerful motivator to seek support and priorities and increase their willingness to engage across the wider system not only for themselves but also on behalf of their children. Support from professionals who were empathetic, flexible and knowledgeable helped parents engage with services. Those who could address a range of needs, mental health, practical support and family needs, were particularly valued. The value and trust established within strong therapeutic relationships could promote openness and engagement with other services and mitigate some of the fear of particular services/professionals. Similarly, peer support networks were seen as playing a crucial role in fostering connection, providing navigation support and offering advocacy.

4.3. Service Improvements

The challenges seen for some professionals attempting to work as part of a complex system of support highlights how inaccessible it must feel to the individuals they work with. To improve service engagement, parents highlighted the need for family-centred, flexible and accessible services, in accessible settings, co-located with other key agencies and offering a flexible approach to appointments. Adopting a holistic, family-focused approach that attended to both parents’ and children’s needs was seen to foster trust and mitigate some other complexity of navigation.

4.4. Additional Insight From Lived Experience Researchers

The inclusion of lived experience researchers was instrumental to this review, particularly given the noted gaps in the existing literature. These researchers added valuable context, enabling the team to better understand and analyse the navigation of multiple services from the perspective of those who have lived through it. Their personal experiences highlighted the challenges of considering all agencies when speaking with a single professional, feeling the need to protect themselves from conversations being shared and misinterpreted.

The lived experience researchers also reflected on the emotional burden families faced when navigating a complex network of services. They further explained that they were also cognisant of professional burnout which can be exacerbated within complex service systems. As a result, they sometimes felt compelled to minimise the complexity of their needs to protect professionals with whom they had established a trusting relationship.

Finally, the lack of research addressing the complexity of multiagency service navigation resonated with the lived experiences of those involved in the study. The researchers emphasised that there was rarely a forum in which parents could consider and discuss the entire network of services simultaneously. As a result, when concerns were raised about the complexity of the service system, their issues were often met with defensiveness from individual agencies, who would shift blame to others instead of recognising the challenges inherent in a multiagency framework.

4.5. Limitations and Future Studies

There are several limitations of the review which should be acknowledged. The review was focused on peer-reviewed publications written in English which may have excluded relevant findings from other languages or within grey literature. This could have included greater insights into the lived experience of navigating services nor reflected differences that may be characteristic of non-Western mental health systems. The lack of specific research regarding navigation meant that a broader scope needed to be applied with a targeted focus within the analysis. We made every effort to identify studies with the search strategy design; however, it is possible that some studies were not identified because of dissemination bias. However, the broad range of clinical expertise alongside the lived and learnt experience of the research team was a key strength of the review, enabling us to adopt an expansive approach to analysis and interpretation. Future studies might explore parents’ and families’ experiences of navigating multiple complex services directly.

5. Conclusion

This review highlights the need for greater recognition of the complexity involved in navigating multiple services and the importance of fostering collaboration and understanding among service providers to improve outcomes for parents with mental ill-health and their families. A notable gap identified is the lack of research directly capturing the lived experiences of navigating multiple services and complex systems of care and support. Existing research, practice and lived experiences consistently show that these families face a wide range of needs and challenges requiring input from numerous services and agencies. This review highlighted a clear and urgent call for research with both families and professionals to better understand these navigation experiences and co-design more effective, engaging, and outcome-focused service approaches.

Appendix A: Electronic Search Strategy

The electronic search strategy was developed in collaboration with a specialist academic librarian. The search aimed to identify peer-reviewed empirical studies examining parents’ experiences of health, social care, education and related services in the context of parental mental illness. Search terms were reviewed and refined both the research team, including people with lived experience in light of the research aim and questions.

parent^∗ or maternal or paternal or mother or father or caregiver or “care giver” or guardian or mom or mum or dad or mummy or daddy N3 “mental^∗ ill^∗” or schizo^∗ or depression or psychos^∗ or bipolar or anxi^∗ or depressive or psychiatric disorder or personality disorder AND parent^∗ or maternal or paternal or mother or father or caregiver or “care giver” or guardian or mom or mum or dad or mummy or daddy AND health and social care” or “social services” or “child^∗ services” or “mental health service^∗” or “family support” or education or housing N3 experiences or perceptions or attitudes or views or feelings or qualitative or perspective.

The following databases were searched:

• APA PsycINFO
• Academic Search Ultimate
• Complementary Index
• MEDLINE Ultimate
• CINAHL Ultimate
• ERIC
• Scopus

Databases hosted on the EBSCOhost platform (APA PsycINFO, Academic Search Ultimate, Complementary Index, MEDLINE Ultimate, CINAHL Ultimate and ERIC) were searched concurrently using identical limits and field restrictions. Scopus was searched separately using equivalent search terms and limits.

All searches were conducted using title and abstract fields only. Database-specific syntax was adapted as required.

Searches were limited to peer-reviewed journal articles, published in English, between January 2014 and December 2024. Grey literature was not included due to the focus on peer-reviewed empirical research.

The initial search was conducted in January 2024 and was updated in February 2025 prior to final manuscript submission.

Across the databases, 10460 studies were identified and imported into Covidence for screening. 3225 duplicates were identified and removed by Covidence, and a further 3 duplicates were identified and removed manually.