Go to: Introduction Owing in part to the international influence of Alcoholics Anonymous (AA), spirituality has long been regarded as important in recovery from addictions ( Kurtz, 1987 ). The 12 steps of AA specifically emphasize personal searching, prayer and meditation, and conscious contact with God ( Alcoholics Anonymous, 1976 ). Some spiritual variables do change significantly over the course of recovery ( Brown, 1990 ; Robinson, Cranford, Webb &Brower, 2007 ), although a causal relationship between these changes and abstinence is unclear ( Connors, Tonigan & Miller, 2001 ; Tonigan, Miller & Connors, 2001 ). Involvement in AA rather consistently shows a modest positive relationship to post-treatment abstinence ( Emrick, Tonigan, Montgomery & Little, 1993 ), and in Project MATCH the spiritually-focused Twelve Step Facilitation therapy ( Nowinski, Baker & Carroll, 1992 ) yielded total abstinence rates across follow-up that were 10 percentage points higher than those for Cognitive Behavior Therapy or Motivational Enhancement Therapy ( Project MATCH Research Group, 1997 , 1998 ). Furthermore, religious involvement is inversely related to the prevalence of substance use, abuse and dependence, both concomitantly and prospectively ( Gorsuch & Butler, 1976 ; Gorsuch, 1995 ; Miller, 1998 ). People entering addiction treatment sometimes show low levels of spiritual/religious involvement relative to the general population ( Hilton, 1991 ; Larson & Wilson, 1980 ; Walters, 1957 ). Studies have also indicated an inverse relationship between substance use and the practice of meditation, both in non-clinical populations and in those undergoing addiction treatment ( Aron & Aron, 1980 ; Marlatt & Marques, 1977 ). All of these findings are consistent with a relationship between spirituality and recovery. Although attendance of 12-step meetings during and after treatment is often recommended in the United States, programs typically do little else to foster spiritual development during the acute treatment phase. There are professional disciplines devoted to facilitating human spiritual development, which could be integrated into treatment. Addiction is among the concerns addressed in pastoral care ( Miller & Jackson, 1996 ), prompting the publication of a Journal of Ministry in Addiction and Recovery . There is also a longstanding tradition of spiritual direction, for which there are professional training and certification programs. Spiritual directors are not necessarily religious clergy, and as with psychotherapy, a wide array of counseling styles is evident, varying in their directiveness and linkage to specific religious traditions ( Guenther, 1992 ; Merton, 1986 ). To our knowledge, there has been no systematic evaluation of the impact of spiritual direction or pastoral care on addiction treatment outcomes. We undertook two clinical trials of manual-guided spiritual direction as an adjunct to inpatient treatment of substance use disorders. Our general hypothesis was that patients given spiritual direction in addition to normal treatment would show increased spiritual practices and experiences during this early phase of recovery, which in turn would lead to significantly greater reduction in substance abuse. Selected psychological variables were also measured as a possible mediation route for any observed intervention effects.