The question of social exclusion occupies a significant place in scientific theories on aging well and in particular those that tackle successful aging. However the two main theories - on disengagement and activity - offer distinct perspectives on this question. In addition, over the past 50 years, French old-age policies have profoundly shifted in their understanding of this issue.
Leading theories on aging
In his 1961 article, Havighurst  defended the idea that “A theory of successful aging is a statement of the conditions of individual and social life under which the individual person gets a maximum satisfaction and happiness…” Havighurst then mentions two theories on successful aging: the activity theory and the disengagement theory. The disengagement theory was not initially a theory of successful aging but a theory of the aging process . Cummings wrote (p. 23) “However, [Erikson]’s model of development can profitably be extended to old age. There does, however, seem to be an implied theory of aging process which underlies many empirical studies. We receive the impression that society withdraws from the older person, leaving him stranded.”
Initially, the disengagement theory unequivocally pointed at the issue of the social exclusion of older people, although the authors claimed that an individual could in some cases contribute to this disengagement process. This theory was subsequently quoted and repeated, which contributed to consolidating its individual, natural and biological arguments . Over the years, the evolution of this concept in publications consolidated its tendency towards ageism .
In contrast with this theory of disengagement, the activity theory - which, according to Havighurst, was essentially supported by those he called “practical workers” - developed and imposed it. It was disseminated by researchers such as Rowe and Khan  who believe that successful aging is «multidimensional, encompassing the avoidance of disease and disability, the maintenance of high physical and cognitive function, and sustained engagement in social and productive activities» (p. 433). Suggesting that successful aging consists in preserving activities and attitudes acquired in the middle age, activity theories promote active and productive aging as a response to social exclusion. As demonstrated by Foster and Walker [6,7], there is a close proximity between the notion of «successful aging», mostly used in the US, and that of «active aging» which is prevalent in Europe.
The laroque report: promoting social inclusion
In France, the Laroque report , drafted by Councillor of State Pierre Laroque (one of the «founding fathers» of the French National Health Service in 1945 brought the focus on the social integration of older people. The report was seen as an instance of «whistle blowing» , and arrived at the conclusion that a growing number of older people in France were affected by pauperization. As the country was going through a phase of full economic growth, many older people suffered from poverty, inadequate housing and social isolation. The report’s objective was to change perceptions of old age, to ensure that people perceived it a phase of life like any other.
In the 1970s policies were developed including the increase of the minimum income for older people, financial support against housing exclusion and the development of home care services and information services to break down the isolation of older people. Politically, social exclusion was seen as a process that led to older people’s exclusion from economic growth. The measures built on this perception strove to help older people benefit from a similar lifestyle to middle-aged people. However, the economic slowdown and the growing focus on disability greatly transformed and narrowed down the scope of old-age policies in favor of the integration of older people. In the 1980s and 90s there was an attempt to quantify dependency and produce adapted responses to what appeared both as a medical and an economic issue. In a general policy context of de-centralization, liberalization and underfunding of social services, the fight against social exclusion no longer appeared as a state priority for old-age policies. Social inclusion issues were thus handed over to local authorities and associations. While in the 60s old age was perceived as another period in life, the 90s became more focused on the «fourth age» and on the functional incapacities associated with this period in life.
The construction of older people’s isolation and loneliness as a public concern
In August 2003, a heatwave brought about a rise in the death rate of about 15,000, with most of the victims amongst the elderly . On the 20th
August, the President of the Republic called an emergency Cabinet meeting and gave a public allocution on the next day. What had so far been a social issue became a political priority. Following these events, the public authorities looked for causes and responsible parties. The President attributed the problem to a lack of solidarity in society, pointing at the loneliness of older people. Measures were adopted in 2003 through the «Plan Vieillissement et Solidarités» («Plan for aging and solidarity»), but the Law of the 30th
June 2004 on solidarity and the autonomy of older and disabled people relegated isolation and loneliness as a secondary issue.
Nevertheless, after 2003, these themes were taken on board by civil society and not for profit bodies and associations, who brought isolation and loneliness issues back on the agenda. For example, the Foundation De France (FDF) regularly published surveys on «loneliness in France», including a 2014 study pointing at the «growing isolation of older people». In 2011, the fight against loneliness was declared a national priority. In 2012, the delegate Minister for older people and autonomy initiated a reflection on older people and isolation. About thirty organizations came together to work on this issue. In 2014, the participants formed the association MONALISA (acronym for “National Action against Elder Isolation”). The working group was led by the general delegate of the charity Les Petits Frères des Pauvres. The group published a report  which recommends to “mobilize” with and for older people on different levels: a national commitment articulated in a common charter; local stakeholder collaboration; the promotion of community engagement and solidarity with older people2
. In 2015, the first section of Law n° 2015-1776 on society’s adaptation to tackle aging included an alinea entitle «Maintaining social cohesion and fighting isolation: MONALISA»3
The objective of the VIEU project was first to document the ways in which some major national stakeholders engaged with the issue of social integration, and secondly to survey older people on their experiences of loneliness. The study had an inductive qualitative design and can be characterized as grounded theory . Two main sources of data were used: institutional documents from promoters, stakeholders and think tanks and interviews transcripts. We carried a thematic analysis on the documents and a grounded theory for the interviews. It implies first to code each interviews, then to create grounded categories and to cross the categories of each interview. Concerning the interviews of old people, this is congruent with an emic posture approach that aims to take into account the participants’ subjectivity as a real source of data. The validation of the codes was done by using a triangulation process. Each interviewer was coded separately by two researchers and compared with literature review and the observation notes made by the interviewers during the interviews.
Social inclusion promoters and stakeholders
The study examined the Foundation De France (FDF) as a major promoter of local anti-exclusion initiatives. As the largest philanthropy network in France, this foundation claims to «act today and prepare the future to meet the needs of vulnerable people through actions that promote social cohesion while respecting their dignity and autonomy4
». Its program targeting «older people» was created in 1975, and releases a bi-annual call for projects entitled «Aging as an actor and a citizen in the local community». We conducted a thematic analysis of this call for projects and an in-depth interview with the head of the program. We also carried out a documentary analysis of 30 projects submitted to the program by local organizations in 2017 to understand the types of applicants and the types of projects submitted. Finally, we considered the association MONALISA as a promoter of social integration for older people, as it incites associations of all kinds to mobilize through its network and offers a charter. We observed several meetings of partner associations to understand their mobilization models and channels of action.
Think tanks promoting the inclusion of older people
To complement this approach, we examined two associations that function as think tanks. Both develop steering groups and study days to promote the social integration of older people. Both associations are also often present in the media and in scientific platforms. REIACTIS (“International Network of Studies on Age, Citizenship and Integration”) is an association that delivers social science research projects and organizes debates on the themes of citizenship and aging. Volunteering for older people and community participation are the two main angles of reflection. This association also presents itself as a “knowledge-sharing network on gerontology”. Old up is an association of older people created in 2007, whose objective is «to attach meaning and usefulness to the growth of life expectancy», and to «change minds and society» with respect to older people through training courses, talking groups, events...
We carried out a thematic analysis of the contents of both associations’ websites. We also conducted an in-depth interview with the President of REIACTIS and the Vice-President of Old up. We used semi structured interview guides to shed light the conception of social inclusion and to precise the actions in progress. The interview guide included three main sections: presentation of the informants and his/her professional and associative trajectory, their point of view of social inclusion and the way how they contribute to it, and the past, future and action in progress of their association.
Surveying older people about their everyday lives and feelings of loneliness
One of the project’s objectives was to move beyond the understanding of social inclusion adopted by promoters, not-for-profits and projects targeting older people, and to document the way older people themselves talked about loneliness. We met 25 older people who expressed a form of dissatisfaction identified as solitude, isolation or pointlessness. These people were aged 60 to 95. 5 lived at home, 12 in sheltered housing facilities and 8 in nursing homes; 23 lived alone (3 single, 3 divorced, 17 widowed and 1 living far away from his wife) and two lived as a couple.
The interview guide targeted the expression social isolation and loneliness to distinguish the two notions through the experience of the informant. The framework for the analysis was built using the informants own words in an open-coding model. The words of informants were interpreted in context, taking into account the interaction with the researcher, the life story elements known.
In the context of decentralization, the question of the social integration of older people has been handed over to the not-for-profit sector. Our aim was to objectify the visions of the different players working against exclusion. This analysis highlights two aspects in the struggle against exclusion: promoting social participation and fighting isolation. Both break down into several dimensions.
Promoting activities in the local community
As part of its call for projects “Aging as an actor and a citizen in the local community”, the FDF states that it supports «projects that contribute to creating more active and sustainable social cohesion between older people and the community as a whole, and promote older people’s participation in community activities locally by contributing their skills». This aim rests on several notions: citizenship, social cohesion and community participation. Projects supported by the foundation are required to promote «the engagement and participation of older people», to support «initiatives by older people» and to provide «opportunities for expression and participation».
This call for projects, as well as the interview with the head of the program, reflects a certain perception of social integration. It expresses an ambition to move away from the paternalistic bias of projects supporting older people, which had been the object of much criticism in the 1990s. Individuals must take an active part in their aging, in their health and in their local community. These elements are articulated through the notion of citizenship, which denotes that individuals are encouraged to take part in the life of the community. The social integration of older people is understood on a local scale - the local territory, the city, the neighborhood - and local stakeholders are tasked with building projects that can achieve this. Active and productive participation in the community is seen as a key factor of integration for older people.
The phrasing of this call for projects associates aging well with local community engagement. Out of 30 responses to the call, 24 were submitted by associations, 2 by public health bodies, 2 by supported housing facilities, 1 by a nursing home and 1 by a municipality. As expected, most proposals replicated the call for projects’ words and spirit in their stated objectives and descriptions. A performing arts charity explained that the objective of their work was to “break down the isolation of older people and support them to become active members of society”. The project targets nursing home residents, with an artistic performance on the theme of the aging body. Being an active member of society is understood as one’s ability to get their voices heard and convey a message that can create more encounters and sharing. The word “active” is closely associated with the notion of social and local inclusion. Artistic creation contributes to giving older people a more active and productive image and creates community cohesion.
Most projects articulate usefulness and social integration with the continuation of working life. For these associations, usefulness refers to the fact for a person to have a place in society, for instance by «re-asserting the value of economic interaction with the rest of society and the ‘active’ population» to quote one of the projects. The FDF, along with the associations that respond to its call for projects, sees local community involvement as a means of creating bonds between people and as a protection against loneliness and isolation. Exclusion is tackled through the promotion of citizen involvement with the support of civil society organizations.
Promoting citizenship and empowerment
These mentions of citizenship in the Foundation de France’s call for projects are echoed by REIACTIS, whose president calls for more «citizen participation». The network defines citizenship as the fact for older people of being involved in the decisions that affect them. Individuals can maintain a connection to the world and be integrated in social life through community activity and volunteering. By becoming spokespeople for their age group, they are expected to re-engage with their local territory and make their voices heard in public debates. REIACTIS identifies a twofold movement in the exclusion of older people, thus reactivating the theory of disengagement. On the one hand, this initiative points at a process of disengagement from society: “A person becomes a recluse at home because they are not socially integrated”. On the other hand, it makes individuals responsible for their own exclusion, which is seen as an individual psychosocial process: “Society is not adapted for individuals who marginalize themselves [...] invisibility is due to the internalization of exclusion by older people [...]. We should help people move beyond the acceptance of reclusion and make them more proactive in the world that surrounds them”.
It is considered that society provides opportunities for older people’s integration, and that such opportunities should be grabbed: this is considered as the main channel of social participation. The president of REIACTIS supports “an approach that starts from an individual’s capacities and resources, which form part of a life project”, and defines empowerment as an individual’s control over their own life and environment. Although it criticizes the utilitarian and functionalist bias in the notion of “usefulness” when applied to older people, REIACTIS nevertheless purports to “identify ways in which people can be supported to continue to actively participate in community projects”. It promotes “opportunities to wake up to the world through conferences and training courses”.
Preserving a place in society
According to the Vice-President of Old up, preserving older people’s role is a way of ensuring their integration. An individual’s role in society is associated with being able to make a contribution on issues affecting society and to form a community group. To achieve this, this association seeks to create “new social participation opportunities” to ensure that older people can lead productive lives. To make a contribution in this world, the founder considers it essential for older people to improve their command of new technologies and communications: «to stay alive, contribute to the life of the community [...] and carry on learning». In a naturalist perspective where aging is valued, she adds: «Paradoxically it is thanks to our very frailness, slowness, declining strength and slower reflexes that we are able to gain this new panoramic vision». Against mainstream representations, she claims that old age is not an obstacle but can be a source of added value when looking for one’s place in society.
This social role involves making a distinction between «meaning» and «leisure». Old people’s activities should not just be designed to help them fight boredom or fill their schedules. In short, they should be different from activities in senior citizens’ clubs or nursing homes, whose sole objective is to keep participants busy. On the contrary, the association’s activities aim to fight the loss of meaning. According to the vice president of Old up, the feeling of uselessness begins when older people feel like they do not have a meaningful place in society. The aim is therefore to “preserve the right for people to exist with their own opinions”.
In parallel with social participation, addressing isolation is a second lever to tackle the social exclusion of older people. This struggle against isolation and loneliness promoted on a local scale is in one of the outcomes of the MONALISA national program.
Loneliness and isolation: a lack of clearly defined terms
Our analysis of the projects submitted to the FDF shows that most project leaders mention the notions of isolation and loneliness. However, a closer reading of the proposals shows that both words are used indistinctly as synonyms, although they refer to separate issues. The confusion between these two notions can for instance be found in this extract from a project proposal submitted by a hospital: “Isolated older people are signposted from the moment they join the nursing home. We take measures to address loneliness (collective meals, offer to take part in daily activities)”. While social isolation is a measure of the number of a person’s social contacts, loneliness refers to a feeling of dissatisfaction due to the quality of these contacts . It is therefore not clear that the proposals address both social isolation and feelings of loneliness. The actions that aim to tackle loneliness and isolation in FDF applications or in projects delivered by MONALISA members are mostly based on two types of activities: getting older people out, and visiting older people.
Visiting older people
In most projects submitted to the FDF call for projects, loneliness and isolation are tackled through activities that aim to get older people out of their home. Those might include IT classes, sport or cultural activities. However, the local charities that deliver such projects observe that they only reach a small portion of their target population. The manager of a community center explains: «It’s always the same people that attend, and they are certainly not the most isolated ones». To address this, MONALISA members work to reach out to isolated older people. This can involve different actions. Some charities worked with a neighborhood-wide network to create a list of people considered as isolated. They then offered to call these people regularly to hear how they were doing and talk over the phone. Some charities take this a step further and enroll volunteers to visit isolated people. The volunteers involved in this type of project sometimes report that they find it challenging to be accepted by beneficiaries, and note that many of them do not wish to benefit from this action.
According to the vice-president of Old up, this kind of “charitable” interaction contributes to patronizing people rather than helping get out of isolation. This type of action can indeed strip its beneficiaries of their individuality and even stigmatize them. Because there is no reciprocity in the relation, individuals are deprived from the possibility to exist through sharing, which can increase their feelings of loneliness and uselessness.
Sharing and exchange
The vice-president of Old up believes in sharing with older people rather than visiting them and in creating mutually beneficial relations. Engagement should not be “top down” but should create a relation of equality that allows a place for both parties, based on the principle of reciprocity of giving. She adds that the more this “sharing add value to society”, the better our chances to tackle isolation because meaning derives both from the relation and from the value it produces. A volunteer’s involvement should therefore go beyond one-sided charity, and avoid creating relations of dependence to instead foster mutual dependence. Interviews with older people tend to confirm that the absence of a predetermined motive for a visit makes the interaction more neutral and therefore less stigmatizing for older people. An interviewee said about a visitor: «You see, he came to see me just like that... for no reason... it’s more than if he had come for a reason. It means that he actually came for me».
Learning to talk with older people?
One of the most active associations in the MONALISA program raised the question of volunteer training. They observed a fact that was confirmed in one of our public meetings: those volunteers were unsure how to address older beneficiaries. Furthermore, the person who asked the question was himself a senior person. These questions were the starting point for the “FORLISA5
training program”, which aims to “complement the national citizen training designed by MONALISA to cover wider needs that emerge from the grassroots6
”, in particular in terms of communication with older people.
This work raises a key issue: should people be trained to talk to older people? Is there not a form of ageism in thinking that these people are so different that we need to learn a specific language to communicate with them? The vice-president of Old up supports this view: “Old people are dead wood, they’re seen as a burden in today’s society, we don’t know what to do with them, and there is no longer a place for them. It’s a bit like talking to inmates; we don’t really know how to address them because they are not really human beings anymore [...]. We don’t know how to talk anymore, we don’t know what to say to them and how to say it, and what are we supposed to say to them anyway? [...] are we trying to turn them into respectable people like you?” Considering that a training program is needed to talk with older people contributes to keeping them at a distance from the rest of society and “ostracizing” them. In addition, activities aimed at tackling loneliness lead to the institutionalization of social bonds, which are potentially disconnected from regular social life. In attempting to respond to the objective situation of social isolation, we forget to consider older people’s subjective experience of loneliness.
Diverse forms of loneliness
To bring a counterpoint to these projects that target older people, we collected the views of people who recognize that they suffer from loneliness and expressed a general dissatisfaction about this. Some interviewees confirmed that loneliness is not always something that people are forced to endure, but can also be a choice  when, due to certain circumstances, the presence of others can be a burden. In our study, eight interviewees expressed a feeling of loneliness, whether explicitly or implicitly, and on different degrees. These interviewees reported that they had access to a limited social circle with few elective connections. Three kinds of loneliness can be found in our corpus: the absence of a partner, the absence of family bonds and the absence of significant friendships. For Mrs. Denise, loneliness is associated to the impossibility to share her sufferings with a trusted friend: “And sometimes you suffer, sometimes you may suffer morally because often you’re not understood. [...] Oh well I just need someone who could listen to me [...]”.
It appears that the intensity of this feeling varies over time . Loneliness is felt more acutely during the festive period and holidays, because people feel excluded from the sharing and celebrations. Mrs. Louise says: “We used to have friends and eat together every Saturday for instance, but that is all gone now...” In everyday life, loneliness can be felt more acutely at certain times of the day, during meals when that moment used to be shared with relatives, or in the evening when the night falls and the outside noises go quiet. Mrs. Simone lost her appetite because she feels “too lonely”, while another interviewee (widowed, 74 years old) explains: “It gets the hardest at night when I’m in bed... There is too much silence, not a sound, silence makes me anxious, and that’s the hardest part, being alone at night. When I’m in bed, not hearing a sound.”
Older people face loneliness without asking for any help and do not necessarily express the need to receive a visit from a stranger. They often use the television, and even more often their memories. Mrs. Raymonde: “Well I watch television and I doze off [...] and sometimes I tell stories to myself. All of a sudden, a memory comes back [...]. And I talk to myself. I often talk to myself [...]. And I remember anecdotes...”
Loneliness requires a reorganization of a person’s way of life (Campéon, op. cit.). They may abandon some of their everyday habits: cooking, knitting, looking after them... In the absence of any human contact, such activities may feel pointless and energy-intensive. People who live alone can also sometimes neglect collective activities that lose their meaning when they are not shared. This leads to a form of withdrawal within one’s home. It appears that to tackle loneliness, someone’s presence is not sufficient. This presence needs to be significant. According to the vice-president of Old up, this requires moving beyond co-presence, to build a relation. This is only possible if visitors also consider themselves to be on the receiving end, and that the older person is in a position to give. She explains: “I believe that in order to help someone out of their loneliness, there should be a reciprocity of giving, that is if you want to help a neighbor out of their loneliness you should go ring at their door, tell them you’re making a cake and you forgot to buy some butter. Place them in a situation where they’re the one giving you something, and not the other way around.”
Replacing the driving principles and activities designed to tackle exclusion in perspective with older people’s opinions drive us to reconsider the question of social inclusion. The review made by Gardiner and al.,  showed that it is difficult to determine which the interventions and activities could reduce social isolation and loneliness and mostly that how it function. The main way leitmotiv seems to be “adaptation”. On another level, the work of Sundström et al.,  showed that healthcare professional have their own representation of the reasons of loneliness for old people. Our results advocate for a qualitative analysis of the feeling of loneliness expressed by old people. Indeed, it appeared that the descriptions of loneliness of old people we met were quite different of what the health care professionals interviewed by Sundström et al.,  Bodily limitation or fear of encountering existential issues are not evocated by our informants. Therefore, the will to preserve privacy seems important without being a barrier to meet new people. We defend that the type of the activities is less important than the quality of the link created with the professional or the volunteer.
Care volunteers and professionals can provide support for isolated people, provided that the relation is perceived as significant by the latter. Professionals can in some cases contribute to reducing feelings of loneliness and creating meaning. In order to do so, a relation of trust must be established, based not only on professional skills but on the sharing of a form of intimacy that is inherent to the relation of care. To ensure that older people can feel that they’re “like everyone else”, their social circle, whether professional or not, needs to become engaged in this relation and to not just consider them as recipients of help. This observation can bring us to challenge the boundaries of professionals’ engagement with older service users .
Older people’s feeling of uselessness is attached to the impossibility for them to give and give back. If a person is in a position where they cannot give back what they have been given, then they lapse into the unrewarding position of a recipient of help. In this perspective, reciprocal giving  must be at the very heart of the relation. For older people, being useful does not mean being busy or socially productive, but rather being in a position where they can give something to the people they consider. In contrast, for charities, being useful is achieved through making a contribution to the community as a citizen. This injunction can be an impossible task for many older people, and it can also narrow down the meaning of the notion of usefulness. Older people want to play a role, to be useful in everyday life and to develop relations of proximity. We should therefore challenge perceptions of social participation that present usefulness as a form of utilitarianism, as is sometimes the case in the rhetorics associated with the «silver economy».