Providing therapy for child and adult sexual abuse survivors is a complex area of therapeutic practice. A nationwide survey was undertaken in order to investigate the decision-making processes of practitioners working with child abuse survivors. Forty-one child-focussed practitioners and 113 adult-focussed practitioners responded to open-ended questions about indicators of sexual abuse, and the factors informing their therapeutic decisions. Thematic analysis of their responses indicated nine themes: indicators of sexual abuse, safety, need for disclosure, the therapeutic process, working with emotions and behaviours, taking a developmental approach, influence and involvement of the family, working with external agencies, and intuition and experience versus evidence-based decisions. How these themes inform decisions made by practitioners and their implications for strengthening clinical judgement through professional development is discussed. In addition, the implications of these findings and their potential to enhance the psychotherapy training needs of clinical psychologists will be discussed.