Starting up user-focused monitoring projects: trust and conflicting expectations in user involvement practices

User-focused monitoring (UFM) is an emerging method for user involvement and quality development in the Swedish mental health sector. It involves people with lived experience conducting a systematized evaluation of a mental health service or support programme. The aim of this study is to analyse motives and central concerns when initiating a UFM project. Five UFM projects in Sweden were sampled, 16 semi-structured interviews were performed with user monitors and commissioners and analysed using conventional content analysis. Our results showcase a range of motives for conducting UFM, illustrate the centrality of trust in the relationships of the UFM practice and the varying degrees of user autonomy in UFM projects. We further discuss our results in relation to epistemic trust and organizational learning theories. Accountability processes are discussed as important for securing continuous trust between the stakeholders. Furthermore, trust is required for UFM being applied to engage in continuous learning and review of organizational norms and goals together with service users.


Introduction
User-focused monitoring (UFM) is a peer-led method of independently and in a systematic manner evaluating mental health services (Jakobsson Lund and Rosenberg 2007;Kotecha et al. 2007).The method has been recommended for empowering people with lived experience in relation to the quality development and evaluation of mental health services (Sweeney and Wallcraft 2010).In Sweden, UFM, as well as methods such as shared decision-making in care planning (Grim 2019), peer support workers in services (Rosenberg and Argentzell 2018), and user advisory boards (Rosenberg and Hillborg 2016) are examples of strategies that have been promoted for integrating user involvement at different levels in the mental health system.In this study, we specifically turn our focus to the start-up phase of a UFM project and explore motives and central concerns when initiating this type of structured approach to user involvement in service evaluation.
The UFM practice draws on research methodology and can therefore be linked to the extensive field of research focusing on user involvement in research (e.g.Lambert and Carr 2018;Sangill et al. 2019;Videmsek and Fox 2018) or service user/survivor research (e.g.Carr 2019;Landry 2017;Rooney 2023).Furthermore, several studies have discussed user involvement in service evaluations (e.g.Clark et al. 1999;Hall et al. 2018;Oades, Law, and Marshall 2011;Perreault et al. 2010;Simpson and House 2002).However, studies on peer-led service evaluations such as UFM are lacking, despite calls for research on user involvement at an organizational level and research focused on user involvement in service development and evaluation (Rosenberg and Hillborg 2016;Semrau et al. 2016;Socialstyrelsen 2012).Further, a lack of research on motives for engaging in user involvement has been noted (Neech 2015).Central concerns and motives for engagement in the start-up phase are key to establishing the agenda and defining the relations that set the stage for the implementation of user involvement methods.

UFM and the Swedish context
The Swedish welfare context for UFM has been discussed as a social democratic regime (Esping-Andersen 1990).Despite an increase in private and non-profit providers, the public sector remains the principal provider of mental health services (Markström and Karlsson 2013) and dominate as the commissioner of UFM.The Swedish health care system is further marked by sectorization.Municipal social psychiatric services provide residential, vocational, and social support, while region-based inpatient and outpatient care focuses on specialized medical and psychotherapeutic treatment.Close relationships between user organizations and the public sector distinguish the Swedish context (Näslund, Sjöström, and Markström 2020) for UFM.
In Sweden, UFM evaluations are commonly conducted by user organizations and commissioned by service providers.There are several UFM models in practice in Sweden today, most of which employ qualitative methods (Canow 2018;NSPHiG 2015), but some also use quantitative methods (Larsson and Svenonius 2018).User monitors are trained in the method, commissioned to design a UFM and collect data at the service site through interviews or surveys targeting service users (hereafter abbreviated to SUs).By analysing and collating the data, user monitors produce a report to provide an understanding of how a service or support programme is perceived by its SUs, including recommendations for future improvements.A prior mapping study of 136 UFM reports (Näslund, Grim, and Markström 2022) showed that services such as inpatient and outpatient care, as well as community mental health services focusing on accommodation and vocational rehabilitation, are frequently the focus of UFM.In Sweden, UFM is often conducted by larger user organizations that have structures to support the implementation of this type of systematic user involvement method.In recent years, there has been an increase in the number of UFM projects that are followed up by a re-visit to the service site.This may lead to services being held accountable for concrete change as a result of user involvement initiatives (Näslund, Grim, and Markström 2022).
In this study, we turn our focus to the start-up phase of UFM projects.Drawing on interviews with user monitors and UFM commissioners at the start-up phase of five UFM projects, the aim of this study is to analyse motives and central concerns when initiating this method.This will further enable a discussion of how sustainable user involvement is installed and established in the development of mental health practice.

Arguments for user involvement
A number of arguments for user involvement have been put forward, and such arguments are often linked to ideals related to democracy or the market (Beresford 2020;Hultqvist 2008;Jones 2021).With a specific focus on SU evaluations, Vedung and Dahlberg (2013) discuss eight motives for user involvement that all relate to the UFM practice.These motives are interlinked but showcase nuances in reasons actors can have for engaging in UFM.Most evidently, the method connects to adaptation of services by focusing on adjusting services to SUs' needs and demands.Greater efficacy can further be supported since increased responsiveness to SUs' needs and preferences potentially means that services can be streamlined in terms of costs and according to rational ideals of goal attainment.Methods can be developed by integrating SUs' perspectives in service evaluation.Furthermore, UFM relates to an equalization of power with the aim to empower and give voice to SUs and to reduce power imbalances in the service system.UFM could potentially strengthen the legitimacy of public services (Vedung and Dahlberg 2013) by anchoring decisions regarding service system change among SUs.
UFM also relates to motives for user involvement that are not primarily concerned with mental health service developments, but rather with broader social change or benefits of direct value to the individuals that participate.UFM can support civic education (Vedung and Dahlberg 2013) by strengthening the capacities of the user movement and by strengthening SUs' competencies to participation.Through motives focused on expressivity UFM can also support the personal development of the participants, including both user monitors and informants.Similarly, UFM can function as a form of self-help (Vedung and Dahlberg 2013) through mutual learning and support.A diversity of motives is thereby associated with UFM, and which of these are in focus may diverge among the actors involved in UFM projects.

Methods
Prior to undertaking this study, a project group was set up that included the researchers, representatives of the user movement, and public sector commissioners of UFM.This project group provided input throughout the research process.

Data collection
Five UFM projects were sampled for this study.The selection of these was guided by a previous mapping study of 136 UFM reports from the past few years in Sweden (Näslund, Grim, and Markström 2022).Based on insights from this mapping study, our sampling was guided by an ambition to include UFM projects that represented common project characteristics, but also the diversity within the UFM practice.We included UFM projects from the three organizations that carry out the largest number of UFMs in Sweden.We also included one UFM project carried out by a user organization that conducts a more limited number of UFMs because the preconditions for performing this type of systematized method for user involvement can vary between larger and smaller organizations.Most UFM projects conducted in the mental health sector in Sweden are based on qualitative methods.We included four UFM projects that employed qualitative methods and one that used a mixed methods approach.The services examined in the UFM projects were also considered in the sampling in order to represent a variety of service contexts and to reflect the fact that accommodation services are the most common type of service examined in Swedish UFM projects (Näslund, Grim, and Markström 2022).We included UFM projects performed in two municipality-based accommodation services, two region-based inpatient care services (a forensic psychiatry hospital and a child and adolescent psychiatric unit), and one daily activities programme that is user-run by a non-profit organization (Table 1).
We gained knowledge of the UFM projects that were about to be initiated through our project group and contacted the coordinators of each UFM project to inform them, and the commissioners, of the possibility of participating in the study.An information letter was sent to all participants.Interviewees were selected based on the specific circumstances of the UFM project.In some UFM projects, the same people coordinated the UFM project and performed the data collection.In such cases, only the UFM coordinators were interviewed.Two UFM coordinators wished to be interviewed together.In other cases, we chose to interview user monitors when they had a central role in both planning and performing data collection.For one UFM project, we further interviewed both coordinators and user monitors in order to obtain information on both planning and data collection procedures related to the start-up phase.Interviews with commissioners typically targeted unit managers who had been actively involved in the commissioning and planning phase of the UFM.For the UFM project focused on a non-profit organization, board members who were involved at the planning stage were interviewed.All interviewees received written and verbal information on the study, and written informed consent was obtained from participants.No information trackable to unique individuals was included in the presentation of the results.The study was approved by the Swedish Ethical Review Authority (2021-02550).Digital or telephone interviews were performed at the stage when the UFM projects had been planned for but when the data collection had not yet been performed.Semi-structured interviews (lasting 28-65 minutes) were conducted with user monitors/UFM coordinators and commissioners involved in each UFM project.The focus of the interview guides had been discussed and adjusted in the project group.For the user monitors, the interviews focused on experiences of the commission and on the planning process for the UFM.For the commissioners, the interviews focused on motives for the commission and expectations for the upcoming UFM.In total, 16 interviews were performed and transcribed verbatim.The interview transcripts were analysed using conventional content analysis (Hsieh and Shannon 2005).Transcripts were first read through and coded inductively, and codes were then clustered into preliminary categories and subcategories.We had ongoing meetings in the research group to compare coding and analytical ideas.Discussions in the larger project group were further integrated in the process of validating the preliminary analysis.When codes and categories had been discussed and evaluated, the first author returned to the data to conduct a deductive coding of the interviews based on the inductively derived categories.The presentation of the results is structured by these categories, and the results are related to the motives for user involvement presented by Vedung and Dahlberg (2013).

Results
Our analysis of motives and central concerns when initiating a UFM project illustrated how trust was central to all relationships that define the UFM practice, that a range of motives for conducting a UFM project was visible among the actors involved, and that the degrees of user autonomy at the start-up phase varied greatly.

Juggling contradictory expectations
From the interviews, it was evident how the UFM projects were often based on dual, or at times even contradictory, expectations.Many of the commissioners hoped for results that included a critical perspective on the current practice in order for the UFM to be used as a foundation for organizational development.However, these expectations often appeared alongside expectations of approval of the current practice to be communicated to external actors.This could potentially pose a challenge to the user monitors in their work, as they need to juggle the expectations of both confirming and contradicting results.

External legitimacy
In several of the interviews with commissioners, an underlying expectation of confirming results was visible: 'So, we're hoping that the SUs also notice that we have a clear communication . . .That's where we hope it lands.It's a bit like I'm now discussing results, but I'm presenting my hopes' [Commissioner 1].Expectations for the UFM results to validate the current practice were often related to underlying motives of external legitimacy (cf.Vedung and Dahlberg 2013).For instance, to organizations reliant on external funding, positive UFM results was noted to be of value in communication with external actors.Commissioners also linked UFM to external legitimacy as a way to achieve political goals: 'I have included an activity based on the political goal that we should work with participation ' [Commissioner 3].Some user monitors reflected on the risks of UFM being used as way of gaining such external legitimacy: '[T]here's always a worry in conducting UFM . . .that they just want it to look good for the statistics' [User monitor 10].Such motives were further connected to risks of co-opting the UFM practice.However, the UFM practice also relates to the external legitimacy of the user organizations that conduct UFM.The user monitors discussed how it was important to deliver UFM reports of good quality in order to get future requests.The legitimacy of the UFM method was further seen as extending to other activities of the user movement.

Internal development
At the same time, many of the commissioners expressed a wish for critical findings that would make deficits visible and that could thereby be used as a foundation for development work: [W]e hope that it will be a ground for improvements of what we already have, what's already going on.That we get strong voices regarding the SUs' opinions that can have an impact.I hope that everyone doesn't think it's all great.[Commissioner 1] Ambitions to utilize UFM results in service development connect to goals of method development and adaptation of services (Vedung and Dahlberg 2013).Commissioners had hopes that UFM would provide a forum where SUs would 'dare' to voice their opinions.Several further wished for the UFM to contribute with insights into development areas that they had been unable to recognize themselves.UFM contributing with a user-specific knowledge perspective was especially highlighted by the user monitors: [W]hen he said: 'I've never thought of the need for a roof over the entryway -what do you mean a roof over the entryway?'Well, the patients had wished for that.They stand there waiting to be let in, regardless of the weather.As a staff member he could walk right in, he didn't have be bothered with it.In that, they had understood what a UFM is and what it can lead to.It's not about the opinions on the service provision of the hospital, the management or the staff, but those of the SUs.[User monitor 6] To integrate these insights into development work, the importance of delving into UFM results and adopting a learning-oriented position was raised.Avoiding adopting a defensive position, but also providing time and space to anchor and process UFM results in the staff group were seen as essential for utilizing the results.

A practice that centres on trust
A recurrent subject in the interviews with both stakeholders was the different aspects related to trust in the UFM practice.Several relationships were trust-dependent, including the relationship between service providers and user monitors, between user monitors and user informants, and between SUs and service providers.Trust was central to performing a UFM project, but this trust was also tested in the UFM process and was sometimes discussed as being breached.

Between service providers and user monitors
In most interviews, the commissioners and the user monitors discussed their relationship in terms of a reciprocal trust.This trust was often explained as a trust in UFM based on it being a structured method: [W]e have this good cooperation already with [the municipality] . . .we have some form of established trust.That they just consider it to be a good thing for us to have control of the situation and already have a method for it, so they simply rely on us.[User monitor 3] The structured approach in UFM provided security for all parties involved and was further seen as efficient by contributing with complementary knowledge in service evaluation: [T]his confidence in the user movement being competent and having effective methods to empower its own target group.That we have something to contribute with, to complement professional knowledge.[User monitor 4] Such motives for engaging in UFM, based on the inclusion of SUs' experiential knowledge in service development, can be connected to method development (Vedung and Dahlberg 2013).The commissioners also discussed the professionality of the user monitors in relation to trust: Being a user monitor is a profession and it has been built up during a long time . . .Today, I feel confident that the UFMs that we commission are conducted in a very competent and professional manner [Commissioner 1] From a service provider perspective, the autonomy built into some UFM models further requires them to trust the user monitors.From the user monitors' perspective, the UFM practice also requires that they trust the staff: '[W]e are completely dependent upon staff really, because if staff doesn't want this to turn out well then they talk negatively about it to the patients' [User monitor 6].Statements about the importance of mutual trust highlighted the relational aspect of UFM, but also power inequalities embedded in the practice.In particular, the commissioners were in the position to choose to extend trust to the user monitors, who in turn depended on such trust to secure future project commissions.At times, user monitors also depicted an uncertainty about their ability to trust service providers.Such uncertainties were especially visible in relation to trusting the service providers to take action based on the UFM results.

Between user monitors and service users
Another relationship discussed in terms of trust was that between the user monitors and user informants.The trust that can be established in this relationship was seen as one of the key elements of the UFM method.For instance, user monitors described how shared experiences can allow user informants to relax in sharing information with them: '[W]hen you share with the informant that you have lived experience of mental ill health, shoulders sort of drop.They dare to share in a completely different way' [User monitor 1].In this process, the greater power symmetry that is established in UFM was highlighted as crucial and as based on having shared experiences.
Autonomy and anonymity, which are key features of the UFM method, were also important to establish trust.Anonymity could, however, be difficult to ensure, especially in accommodation services, where it could be challenging to confidentially conduct interviews.Autonomy was related to the importance of meeting the user informants independently in order to establish peer-to-peer trust.The UFM practice is built on ambitions to equalize power relations (cf.Vedung and Dahlberg 2013), and the peer-to-peer focus of UFM can contribute to greater power symmetry during the UFM process with the hope of extending re-negotiated power relations to the general practice.

Between service providers and service users
The UFM practice also relates to trust between SUs and service providers.Interviewees described how SUs' confidence in the value of voicing their opinions had sometimes been fractured by past experiences.UFM was thereby seen as part of a process where trust needed to be established between SUs and service providers before conducting a UFM project.UFM could also strengthen trust between SUs and service providers: To a large extent it's about getting that trust from the SUs, that they dare to open up and share if something hasn't worked so well or about something that they wish to have differently.Trust in expressing your opinions in that way, and that they get feedback on it.It would have been fantastic to get that trust, via UFM.[Commissioner 3] This increased trust could potentially lead to a new culture in which SUs are empowered to voice their opinion and participate more actively in services moving forward: [T]he SUs should feel that they gain trust in the service provider and that they actually feel listened to.That it's possible to improve and develop things based on what they say so that they get more confidence in doing that, in voicing their opinions.Not just in the UFM, but also in other ways.[User monitor 3] Thereby, motives such as expressivity (Vedung and Dahlberg 2013), where SUs are empowered to engage more actively in the service, were mentioned by the interviewees.However, the UFM process could also act as a test of this trust: [I]t completely depends on how you utilise the UFM, whether you achieve improvements . . .Because if you only perform it as a grandstanding, it won't increase trust but rather undermine it [User monitor 9].Receiving feedback on what happened as a result of the UFM was emphasized by the user monitors as important for making participation meaningful and for not damaging trust.

Main UFM beneficiaries
One of the tensions in the interviews regarded who was the main beneficiary of UFM.Several commissioners described it as a practice that primarily benefits services in their development goals.This could be compared to a traditional understanding of an evaluation where goal-achievement is assessed with the ambition to develop an organization to better meet these goals.However, user monitors to a greater extent discussed UFM as a practice that primarily and directly benefits SUs, for instance, by supporting empowerment processes.

A service provider affair
Unit managers were frequently the initiators of UFM, and the commission was in most cases related to managers' engagement and drive to develop the quality of their services.Commissioners were often engaged in user involvement issues in general, and several had previous knowledge of the method.Furthermore, some commissioners described how it was mainly their responsibility to work with the UFM results.This may reflect top-down approaches to user involvement, where it was the manager's interest, commitment, and drive to conduct UFM that enabled the commission.In one of the UFM projects, organizational-and management change marked the start-up phase.This further caused insufficient anchorage regarding the motive for conducting the UFM among both management and staff.
Frontline staff often assumed a more passive role in the commissioning process or in the process of designing the UFM.When anchoring among the staff group is lacking, this could potentially cause difficulties in implementing the UFM method and the UFM results: It's also difficult for programmes when you get it from higher levels . . .because it becomes an additional work activity . . .They are already piled high with tasks and have a lot to do . . .So that you think of involving [staff] too . . .we work with user involvement but they also have to involve their own [employees].[User monitor 8] The engagement of frontline staff in the UFM process was further crucial in order to promote participation among the SU group: '[A]nd yet it's the staff that's important, they know the patients, they're the ones who can allure and wheedle and explain what this is ' [Commissioner 6].Recruitment of informants was frequently a challenge in UFM projects, where the support from frontline staff was described as key.
In some UFM projects, user monitors were to a limited extent involved in the planning and design phase, which was rather the responsibility of the UFM coordinators.Furthermore, in only one of the projects was the user group at the service site involved in the process of designing the UFM.In one of the UFM projects, the results were not planned to be reported back to the user group because the UFM was regarded as more of a service provider affair: 'We haven't thought of providing feedback to the SUs at all.[W]e have probably thought of it as a service provider thing, so to speak.That it's ours ' [Commissioner 1].This position aligns with a focus on UFM as a method primarily focused on service adaptation, method development, and efficacy where the experiential knowledge of SUs is utilized to streamline services according to objectives of goal completion (Vedung and Dahlberg 2013).The commissioners all described that the end goal is for SUs to benefit from the UFM.However, the understanding of who is the main addressee of and owner of the UFM results varied.Perhaps the understanding of UFM as a service provider or even a management affair can hinder engagement from both SUs and frontline staff.

A service user affair
There were also many examples in the interviews, especially among user monitors, of the SU group being defined as the primary beneficiary of the UFM.Some user monitors, for instance, understood UFM as mainly a thing between them and the SUs.Benefits for SUs in participating in UFM were recurrently connected to empowerment processes: That you introduce those reflections and then also show them the possibility to influence things, that it's possible.So that . . .some sort of empowerment process is initiated.To make more demands perhaps, to equalise this balance between SUs and staff.[User monitor 4] Empowerment processes can be individual but can also relate to being empowered as a collective, and such motives for UFM relate to the equalization of power (Vedung and Dahlberg 2013) within mental health practice.Secondary motives for user involvement that place the SU in direct focus are further central in these statements, where participation in UFM for the individual SU can be related to motives such as expressivity, self-help, and civic education (Vedung and Dahlberg 2013).One important aspect to enable such secondary motives was the SUs being considered to be owners of the UFM results: 'That they can also say: "The UFM revealed how we do not get enough food", or whatever it is, "So now we want more food"'.[User monitor 6].Not only were the UFM report and results important to support such processes, but the meeting between the user monitors and the user informants was held as important in itself.For the user monitors too, participation could be empowering: 'And then this meeting is crucial, because we consider it empowering to the SUs but also to us as user monitors.That we get to use our experiences' [User monitor 4].The knowledge generated through the method could further benefit the user movement.Specifically, it enabled forming demands based on information from UFM.This aspect of the UFM method relates to motives of civic education (Vedung and Dahlberg 2013) where the method contributes to strengthening the capacities and knowledge base of the user movement.

Varying degrees of autonomy
The balance between the user monitors and the commissioners in controlling the focus of the UFM varied greatly -from commissioners steering the issues in focus, to those with interests in certain areas, to those who left the entire design in the hands of the user monitors.User monitors also varied in their discussions regarding user autonomy, where some emphasized the need to respect and fulfil the commission, while others appreciated input, and still others wanted control of the UFM design.

Fulfilling the commission
Commissioners greatly varied in their input and control regarding the focus of the UFM projects.Some did not provide any input on the focus of the UFM, while others had expressed certain areas of interest, and in one of the UFM projects the commissioners had fully steered the focus: [W]e have steered a lot because we knew what we wanted to know more about.Then . . .we had an agreement that we need to look at the questions and in that we saw that, now it deviates . . .So, we have definitely steered a lot, because we knew exactly what we wanted.[Commissioner 1] A delimited focus illustrates a specific interest in UFM results that could be applied in adaptation of services (cf.Vedung and Dahlberg 2013).Such steering could be perceived as positive from the user monitors' perspective and as a reflection of the commissioner's engagement: '[T]hey gave the impression of being more driven and wanted to add questions themselves' [User monitor 4].It could further facilitate the user monitors in their work by providing a welldefined focus for their analysis.Some user monitors described how in conducting a UFM project they were performing a service, where it would be disrespectful to disregard the commission: Not like: 'No, no, no!We think you should do it like this.'That would almost be disrespectful, I would say.[T] hey have identified needs.They have confided in us to try to deliver feedback and to see if there's a need for development [User monitor 2] The user monitors also depicted certain frames for what they regarded as a suitable focus for a UFM project, such as a focus on 'surrounding activities' rather than issues regarding treatment.Frames for UFM projects were thereby also set by the user monitors' views on what areas they have competency in addressing.

Demanding control
Certain UFM providers demanded greater autonomy.Some user monitors for instance described how they invited service providers to provide input at a start-up phase, while being clear about them having the final word regarding the design of the UFM.Rather than demanding autonomy, these user monitors discussed how commissioners often accepted their well-established model.Others regarded the autonomy of the user monitors as a central part of UFM: But they have been very clear regarding the focus, that their vantage point is that it's the patients' survey, their interviews.It's their thoughts and opinions that should get through . . . in the very process, in the very handicraft, we haven't had any real insight.[Commissioner 6] Anchorage in the user movement was important in relation to recognizing the value of autonomy.User control was by these user monitors understood as key to a genuine and authentic UFM project, where power is re-distributed: 'It's better that it becomes good and more genuine and correct . . .if it's too much steering and influence from the [service provider] then it won't be user-steered in that way' [User monitor 5].These approaches have a stronger connection to motives of the UFM contributing to equalization of power (Vedung and Dahlberg 2013) by placing user autonomy and control at the core of the UFM project.
To conclude, our results revealed variability between the UFM projects regarding how these were organized and in how the roles of the user monitors and the commissioners were defined.Specifically, the UFM projects varied in relation to user autonomy in the start-up phase, and with regards to who was defined as the main beneficiary of and addressee in the UFM process and results.Trusting relations were seen as fundamental to the success of the UFM projects, where feedback regarding resulting change was described as important to continuous trust.However, motives for conducting a UFM project varied among the actors involved.The user monitors needed to balance expectations of UFM results that confirmed, but also revealed deficiencies, in the mental health practice.Furthermore, commissioners tended to highlight UFM as an input to service development processes, whereas user monitors to a greater extent discussed how UFM could directly benefit SUs by contributing to empowerment processes, and also stressed UFM as part of a broader culture change.

Discussion
Trust-based relationships between the actors involved mark the UFM practice.Our results show that these relationships are nestled in several, and at times vague, intentions for what type of knowledge is to be produced through UFM.All motives for user involvement discussed by Vedung and Dahlberg (2013) were visible in the interviewees' descriptions of motives and central concerns during the start-up phase of a UFM project.User involvement practices frequently connect to a multitude of goals.Prior studies on motives for engaging in user involvement activities have, for instance, emphasized both individual and collective motivations (de Freitas 2015) and the different motives of SUs and professionals (Sargeant et al. 2007).However, if vague intentions are not clarified in a start-up phase, this could potentially lead to the involved actors' intentions not being met, and thereby causing a breach in trust.

Epistemic trust on trial
A concept of relevance to the trust-dependent relationships in UFM is epistemic trust (e.g.Catala 2015;Origgi 2012).This type of trust relates to someone's credibility as a knowledge actor, and Catala (2015, 432) describes two types of epistemic trust: 'experience-based trust' (based on prior personal experiences) and 'expertise-based trust' (based on the recognition of someone's relevant expertise or knowledge).Both forms of trust are relevant to the UFM practice.Relationships between service providers and user organizations are often stretched out in time, beyond a specific UFM project, for instance, through long-term contracts (Näslund, Grim, and Markström 2022).Through such continuous collaboration in UFM, our results reflect how experience-based trust can be established through service providers developing trust in the method.If service providers meet the expectations of the user organizations this experience-based trust can further be mutually built.This underscores the importance of continuity in user involvement practices.However, it should be noted that even though trust is relational in UFM, power imbalances between the actors involved could entail user organizations being more dependent on securing the trust of service providers rather than the other way around.Catala (2015, 434) further discusses epistemic trust as related to 'a substantial criterion of legitimacy and a procedural criterion of accountability'.For epistemic trust to be justified as legitimate, an actor must have the sufficient qualifications to be deemed trustworthy.For user monitors, claims to expertise-based trust both connect to their formal training in the UFM method as well as to their specific social expertise.However, the results revealed that both user monitors and commissioners mainly highlighted the professionality of UFM as a foundation for the method's legitimacy.Commissioners' lack of emphasis on how social expertise and experiential knowledge contribute to the legitimacy of UFM begs the question of why this type of evaluation is to be conducted rather than an ordinary clinical audit.This pattern might be a result of persevering stigma towards people with lived experience, where professional training and methodological competence are still regarded as a more stable foundation for legitimacy.
Trust also connects to whether an actor is accountable, which is continuously assessed in relation to the ability to meet the standards that are required or fulfilling the task at hand (Catala 2015).Accountability thus relates to the performance of the actors involved.If participation in UFM is a positive experience for the user informants, the project is successfully implemented by the user monitors, and if service providers make the most of UFM results, the results of this study suggest that the method could strengthen trust in all the relationships that it builds upon.However, if the user monitors fail to deliver a UFM report that meets service providers' intentions for what type of knowledge is to be produced, this could lead to a breach in their trust in the method.Especially central to our results is, however, how SUs' trust in service providers risks being breached if services fail to act on the UFM results.The UFM process could thereby be seen as a trial of epistemic trust, where the involved actors' trust in each other could be strengthened or weakened.Building in accountability procedures, where service providers demonstrate to the SU group and the user monitors how they have acted on the UFM results, are therefore vital to maintaining trust.The importance of accountability and feedback regarding actual change further extend to user involvement work in general (Grim et al. 2022).

Learning to change action or to change assumptions
Our analysis revealed the range of motives that the actors involved have for initiating UFM projects.Some commissioners described how they had identified specific areas in which they needed input from a SU perspective, whereas other commissioners saw the UFM as part of a more general work towards empowerment and increased user influence.These different approaches could be seen as a reflection of different knowledge interests and approaches to what change they hoped UFM could to contribute to.Davies and Nutley (2000) conceptualize organizational learning at different levels, discussing 'single loop', 'double loop', and 'meta learning'.Single loop learning is focused on stepwise improvements in practice based on current policies and objectives (Argyris 1977), double loop learning requires organizations to engage in change processes by first evaluating basic assumptions and organizational goals (Argyris 1977), and meta learning refers to organizations developing capacities to continuously learn (Davies and Nutley 2000).The different motives of commissioners described in our results connect to these different forms of learning, where SU input on specified issues could be seen as a reflection of single loop learning.With such an approach, different aspects of service provision are evaluated through UFM in order to contribute to improvements of practice through SU input.Ambitions to integrate UFM with a greater focus on strengthened and continuous user influence can instead be seen as a reflection of double loop or even meta learning.Instead of a focus on specific problem areas, UFM becomes a knowledge practice that can contribute to culture change by redefining power relations.Furthermore, the ambition to integrate structures for continuous user involvement enables an approach of constant learning in dialogue between SUs and service providers.
These approaches have their benefits.Double loop and meta learning can be discussed as higher degrees of learning, and in such approaches UFM constitutes part of a continuous learning process, where the organization is fundamentally changed by continuously learning with SUs -and where SUs are empowered by seeing their role in such a learning organization.However, such learning processes are complex and need to be integrated with tangible facilitators of change.Single loop learning, where service providers have formulated a specified knowledge interest for the UFM, has the benefit of service providers being more likely to have available methods to 'make use' of the knowledge that they are requesting.Both approaches might be justified when starting up a UFM project, but they would benefit from being clarified in order to avoid entering into user involvement projects with vague intentions.This further points to an area for future research, to explore what methods service providers have for implementing UFM results.

Trust and learning
Double loop learning requires trust (Argyris 1977) because opening-up organizational norms, assumptions, and policies to critical scrutiny implies a loss of control.Regarding organizational action, single loop learning is focused on achieving the goals as these are already defined, which requires high degrees of control that can lead to defensive norms and a lack of public testing of organizational practice.The actions that are connected to double loop learning are instead focused on acquiring the information needed, where norms are learning-oriented and a less defensive position is adopted, which enables public testing of organizational practice (Argyris 1977).Our results suggest that loss of control in UFM might most evidently be experienced by frontline staff who at the start-up phase lack insight into the process of formulating the focus of the UFM.However, this group is often placed at the centre of the UFM evaluation.For double loop learning processes to be supported, trust in the method from management and staff is key.It is thereby important to explore how anchorage among staff can be secured and how learning-oriented positions can be supported because this is vital for the implementation of UFM and for making the most of UFM results.

Conclusion
Motives for user involvement reflect perceptions on the value of including SUs' experiential knowledge in the development of mental health practice and of maintaining autonomy for the user organizations.A variety of motives are present in the start-up phase of a UFM project, connecting both to external legitimacy, service adjustments, equalization of power relations, collective empowerment, and benefits for the SUs who participate at the individual level.We have further discussed the importance of these motives being clarified at the beginning of a user involvement project so as not to cause a breach in trust due to the intentions of the involved actors not being fulfilled.The importance of accountability mechanisms in UFM have been highlighted.Furthermore, central concerns in the start-up phase of UFM relate to the knowledge interest of the involved actors.Specifically, we have emphasized the importance of a double loop and meta learning approach to UFM, where the method is applied as part of a continuous learning process involving both SUs and practitioners.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Table 1 .
Overview of data collection according to UFM project.