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About the harder stuff, namely combat... Ideally you want to be in an advantageous position during any fight. Seek the high ground, bonus points if it requires jumping to reach it; the player is the only entity in the game that's able to jump, IIRC. Try to get sneak attack criticals, and use weapons & perks which maximize crit damage to make the most out of them. This also means you'll have to use less bullets to kill enemies, saving you a lot of ammunition. Invest in a Sniper Rifle (or you can even find a few just lying around, such as on a bed in the 1st Recon tent at Camp McCarran... Doesn't even need to be stolen, strangely enough). Also, find the Suppressor modification for it. If you need .308 rounds, Contreras at Camp McCarran tends to have a huge amount. That'll get you off to a good start.
I'd avoid the Ratslayer; due to a bug, it's not a proper silenced weapon, so you're better off using a Sniper Rifle w/ a suppressor mod attached, which does work properly. So the Ratslayer, while not a bad weapon per se, shouldn't be relied on for stealth.
Remember, if you can't handle a fight, sneak past it, or simply run. Fight only on your terms.
There are other strategies beyond merely a stealthy build, however. I remember seeing a Youtube video of a guy explaining a build that's very effective on Very Hard mode. It was basically a VATS centered build (picking up the perk Math Wrath, and other similar perks), with the main weapons of choice being Maria (Benny's 9mm, very useful against targets with little to no DT, gets insane amounts of VATS rounds) and the Gobi Campaign Scout Rifle (unique Sniper Rifle, and a surprisingly good weapon for VATS strategies). It also emphasized having a high crit rate. So in a nutshell, a high crit build using weapons that get plenty of rounds in VATS. It also allows you to reliably cripple limbs. For instance, crippling a Deathclaw's legs or a Cazador's wings makes those encounters a lot easier.
Sadly, I can no longer find the video. Back then I created a character centered around the proposed build, played on Very Hard, and it worked quite well. Didn't complete the entire game, though. But I did clear Quarry Junction and similar areas.
Anyway, good luck, and happy hunting
so you could take drugs which increase damage, psycho/Slasher/Med-X.
and would basically change Very hard mode with drugs = Normal Mode without drugs.
such is the nature of damage sliders.
also any semblance of difficulty leaves as you accquire bigger guns and armor.
So I would have suggested some sort of difficulty mod, over the default damage slider the game provides which just makes bullet sponges instead of nuanced challenge.
I would recommend the mod called "Jsawyermod" designed by Josh sawyer the Lead Disigner and Director of the game himself if you want to stick to vanilla feel. it basically a director's cut since it tweak and fix a lot of things. Normal or Hard difficulties and Hardcore mod are recommended.
when you're lvl 1 or 2, chems are extremely useful, but after a few levels, how often do you use anything besides stimpaks, radaway/rad-x, and the auto-tourniquet cause cazzies suck?
or VATS for that matter? Survival + Very Hard are for roleplaying; chems aren't for when you remember them, they become a necessity for big fights, and the difference between plinking away on a seemingly indestructible tank, or dropping them in a few rounds.
if you don't enjoy cooking / consuming foods with perks, crafting / consuming chems, etc. and consider all that just micromanagement that gets in the way of your killin fun? then lowering the difficulty was the right idea! cause VH w/o buffing up = grueling tedium.